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TRI-ATISl-  ()\  n MORS 


BY 

ARTHUR   E.   HERTZLER,  M.D.,   Ph.D. 

ASSOCIATE  PROFESSOR  OF  SURGERY  IN  THE  UNIVERSITY  OF  KANSAS;  FORMERLY  SUCCESSIVELY  PROFESSOR 
OF    HISTOLOGY,    P.'VTHOLOGY,  EXPERIMENTAL    SURGERY,  AND    GYNECOLOGY    IN    THE    UNIVERSITY 
MEDICAL    COLLEGE,   KANSAS  CITY,  MISSOURI;    ATTENDING    SURGEON    TO  THE   HALSTEAD 
HOSPITAL,  HALSTE.^D,  KANS.^S,  AND    CONSULTING    SURGEON   TO  THE   SWEDISH 
HOSPITAL,  KANSAS  CITY,  MISSOURI,  AND  ST.  MARGARET'S  HOSPITAL, 
KANSAS    CITY,    KANSAS;    MEMBER    OF    THE    WESTERN    SUR- 
GICAL    ASSOCIATION,     THE     AMERICAN     ACADEMY 
OF  MEDICINE,  THE  AMERICAN  ANATOMI- 
CAL SOCIETY,   ETC. 


ILLUSTRATED    WITH    538    ENGRAVINGS   AND  8  PLATES 


LEA    &    FEBIGER 

PHILADELPHIA    AND    X  E  W    YORK 
I  9  I  2 


^%s 


H  ^  'J- 


Entered  according  to  the  Act  of  Congress,  in  the  year  1912,  by 

LEA    &    FEBIGER 
in  the  Office  of  the  Librarian  of  Congress.     All  rights  reserved. 


TO    MY    WIFE 


P  R  K  F  A  C  1{ 


1  HIS  treatise  embodies  the  experience  ot  many  years  jiained  in  the 
operating  room,  the  observations  of  laboratory  stud\',  and  the  informa- 
tion gathered  in  the  library,  combined  in  such  proportions  as  my  duties 
in  teaching  students  and  as  a  surgical  consultant  have  shown  to  be 
most  advisable. 

The  aim  of  the  book  is  to  give  students  and  practitioners  a  guide 
to  the  proper  recognition  of  tumors.  Available  books  dealing  with 
this  subject  are  either  broadly  clinical  or  entirely  scientific.  A  proper 
comprehension  of  an\'  tumor  demands  the  application  of  both  the 
scientific  viewpoint  and  clinical  observation.  1  he  aim  has  been  to 
suppl\'  this  need.  For  this  purpose  it  was  thought  best  to  place  the 
chief  emphasis  upon  the  practical  aspects  of  the  subject  and  to  include 
as  well  sufficient  of  the  more  abstract  considerations  to  make  the  prac- 
tical side  broadly  intelligible. 

In  view  of  the  essentialh'  practical  character  ot  the  work  the  vast 
field  of  experimental  oncology  has  been  entirely  omitted,  because,  in 
the  first  place,  the  results,  promising  as  they  are,  have  not  }et  attained 
a  state  of  practical  utility,  and  would  but  confuse  the  student  and  prac- 
titioner; and  in  the  second  place,  those  who  are  engaged  in  tumor 
research  necessaril\'  work  in  laboratories  where  experienced  personal 
guidance  is  available. 

Citations  of  literature  have  been  incorporated  particularly  in  those 
chapters  where  existent  opinion  is  still  divergent.  These  are  presented 
that  the  student  may  follow  the  subject  and  as  an  apolog>-  for  the 
unqualified  presentation  of  the  author's  viewpoints.  Papers,  with 
bibliographies,  most  likely  to  be  accessible  to  the  reader  have  received 
preference.  Inasmuch  as  nearly  one-fourth  ot  all  surgical  literature 
has  to  do  with  tumors,  a  careful  reading  of  all  this  vast  material  is 
impossible,  hence  many  valuable  papers  must  have  been  overlooked. 
Of  those  read,  it  is  a  matter  of  personal  judgment  as  to  which  shall 
be  deemed   the   more  valuable. 

In  the  preparation  of  such  a  work  obligations  of  man\-  kinds  are 
incurred  by  the  author.  My  first  debt  is  to  my  wife,  who  through  man}- 
years  has  kept  together  the  data  that  have  gone  to  make  up  the  book. 
Dr.   Edward  T.  Gibson  and  Dr.  William    J.  Walker  revised  the  manu- 


vi  PREFACE 

script  and  corrected  the  proof.  To  them  I  express  my  appreciation. 
I  feel  a  keen  sense  of  pleasure  at  the  readiness  with  which  professional 
friends  have  placed  material  at  my  disposal.  To  Dr.  J.  W.  Perkins 
I  am  under  particular  obligations  for  the  kind  manner  in  which  he 
offered  his  vast  clinical  material  and  his  large  collection  of  photographs. 
So  unstinted  was  his  generosity  that  his  material  has  become  insepar- 
ably a  part  of  my  own.  Dr.  Frank  J.  Hall  likewise  made  me  a  welcome 
visitor  in  his  laboratory,  where  I  secured  much  information  and  many 
specimens.  Many  others,  the  mere  mention  of  whose  names  would 
be  equivalent  to  presenting  a  roster  of  my  professional  friends,  were 
equally  kind.    To  all  of  these  I  extend  my  appreciation. 

Thomas  S.  Jones  and  John  D.  Bigger  made  nearly  all  the  drawings. 
The  reader  will  himself  be  able  to  estimate  my  great  obligation  to 
them.  The  excellence  of  their  work  is  the  best  expression  of  the  personal 
interest  they  exhibited  in  mine. 

To  my  publishers  likewise  I  take  pleasure  in  acknowledging  m}^ 
gratitude  for  the  careful  attention  bestowed  upon  every  detail  of  the 
work.  Because  of  their  efforts,  seeing  the  work  through  the  press  has 
been  a  pleasure  rather  than  a  task. 

A.  E.  H. 
Kansas  City,  Mo.,  1912. 


C  ()  N  T  U  N  T  S 
p  A  R  r  I 

THE  GENERAL  HIOLOG\'  OF   ILMORS 
Conception  and  Definition '7 

PART    II 

THE  SPECIAL  PATHOLOGY  OF  TUMORS 

CHAPTER   1 
Osteomas 57 

CHAPTER   II 
Chondromas  and  Chordomas     6o 

CHAPTER   III 
Myxomas 64 

CHAPTER  IV 
Lipomas 67 

CHAPTER   V 
Myomas 69 

CHAPTER  VI 

FiBROMAS 73 

CHAPTER  VII 
Gliomas 83 


viii  CONTENTS 

CHAPTER  VIII 
Neuromas 88 

CHAPTER   IX 

Sarcomas 9^ 

CHAPTER  X 

Multiple  Myelomas  . 125 

CHAPTER  XI 

Angiomas 127 

CHAPTER  XII 

Endotheliomas — Cholesteatomas i3S 

CHAPTER  XIII 

Adenomas •      •      •      ■      ^45 

CHAPTER  XIV 
Papillomas ^5° 

CHAPTER   XV 
Carcinoma ^59 

CHAPTER  XVI 
Cysts 203 

CHAPTER  XVII 

Embryoid  Tumors ■ 207 

CHAPTER   XVIIl 

Granulomas 210 


(yj.\n:.\rs  ix 

1V\  k  I     I  I  I 
ki;c;i()\\i.  roNsiDi.k  \Ti()\  ()!•  iiMok.^ 

CM  \l'  I  \:\<    ,\  IX 
Biology  ok    1  imors  and  (iimkai.  L'i.ink  \i.  C"t)Nsii)i;KATif)Ns  219 

CIIAI'IK  K    XX 
TiMORs  OK   riiK  Cranilm 231 

CIIAI'TK  R    XXI 

I  IMORS    OF    rUE    MraIN    and    SlMNAL    CoRD 2^52 

CHAPTER   XXU 
Tumors  of  the  Orbit  and  Lacrymal  Glands 267 

CHAPTER    XXIII 
Tlmors  of  the  Face 276 

CHAPTER  XXIV 
Tlmors  of  the  Nasal  Fossa  and  Pharynx ^09 

CHAPTER    XXV 
Tlmors  of  the  Mouth  and  Tongue -5^5 

CHAPTER  XXVI 
Tumors  of  the  Jaws,  Gums,  Teeth,  Periosteum,  and  Bone  .      .  ^^3 

CHAPTER  XX\II 
Tumors  of  the  Parotid  and  Submaxillary  Glands 345 

CHAPTER   XX\III 

Tumors  of  the  Neck,  Includinc:  Tumors  of  the  Thy'roid  and   Parathyroid 

Glands,  and  Carotid  Tumors  354 

CHAPTER   XXIX 
Tumors  of  the  Chest,  Mediastinum,  Heart,  and  Lungs 391 


X  cox  TEXTS 

CHAPTER  XXX 
Tumors  of  the  Mammary  Gland 398 

CHAPTER   XXXI 

Tumors  of  the  Abdominal  Wall  and  Umbilicus 439 

CHAPTER  XXXII 
Tumors  of  the  Back 446 

CHAPTER  XXXIII 
Tumors  of  the  Liver  and  Gall-bladder 452 

CHAPTER  XXXIV 
Tumors  of  the  Pancreas  and  Retroperitoneum 465 

CHAPTER  XXXV 
Tumors  of  the  Digestive  Tract 470 

CHAPTER  XXXVI 
Tumors  of  the  Urinary  Organs 508 

CHAPTER  XXXVIl 

Myoma  of  the  Uterus  (Fibromas  of  the  Uterus,  Fibroids,  Fibromyomas 
of  the  Uterus),  Adenomyoma  of  the  Uterus,  Myoma  of  the  Round 
Ligament,  Tumors  of  the  Round  Ligament.  Pregnancy  in  Myoma     .      .     536 

CHAPTER  XXXVIII 
Carcinoma  of  the  Uterus 567 

CHAPTER  XXXIX 

Syncytioma     Malignum      (Carcinoma     Svncytiale,      Deciduoma,      Chorio- 

etithelioma) 591 

CHAPTER    XL 
Tumors  (Cystic  and  Solid)  of  the  Ovary,  Tumors  of  the  Fallopian  Tubes     596 


<:(j.\'ij-:.\rs  xi 

CM  API  Ik    \i.i 

TlMORS    (H     nil     \'l  LVA    AND    XacINA  (,26 

ClIAl'IKR    Xi.ll 
I'lMDRs  01   nil    Mali    Cii-MTAL  Orcans    .  .     ^^^^ 

CM  \I'TI   k    XI.I  1  i 
Tumors  of  thl  L  iter  KxiRLMrnts (,-(, 

CHAPTER   XLI\' 
Tl^mors  of  THt  Lower  Extremities 6Ji- 


T  U  M  ()  R  S 


PART    1 
THE  GENERAL  BIOLOCrV   OK  TUMORS 

CONCEPTION    AND   DEFINITION 

\'iRCHo\v,'  in  his  great  work  on  tumors,  says  that  if  one's  life  depended 
upon  it  one  could  not  define  a  tumor;  but  as  Ribbert  justh'  remarks,  the 
difficulty  lies  not  so  much  in  the  inabilit)-  to  define  tumors  as  in  the 
mability  to  conceive  of  their  nature.  W  hen  the  term  was  first  adopted 
into  medical  literature  it  was  sufficiently'  comprehensive  and  self- 
explanator}',  in  that  it  expressed  the  sum  total  of  all  knowledge  of 
tumors,  viz.,  the  fact  of  the  existence  of  an  enlargement  or  swelling.  As 
knowledge  extended  it  w^as  noted  that  tumors  var}-  in  life  histor\'  and 
in  effect  upon  the  host;  that  some  tend  to  destro\'  life  while  others  do 
not.  The  real  difficult}',  however,  began  with  the  microscopic  stud\'  of 
the  structure  of  tumors.  We  date  all  modern  conception  of  the  nature 
of  tumors  from  the  enunciation  of  Virchow's  theory,  that  all  tissue  comes 
from  preexistent  cells.  This  led  to  the  discovery  that  not  all  tumors 
are  due  to  proliferation  of  cells.  Those  which  are  tumors  in  form  but 
not  in  structure  were  designated  false  tumors.  The  true  tumors  were 
called  neoplasms,  to  indicate  that  the}'  were  the  result  of  tissue  prolif- 
eration. Further  stud}'  revealed  that  the  neoplasms  had  to  be  limited 
yet  further  b}'  the  exclusion  of  two  groups:  first,  that  which  comprises 
the  local  multiplication  of  cells  otherwise  normal,  the  hypertrophic 
processes  and  the  like;  and  second,  the  granulomas,  which  resemble  the 
true  tumors  in  structure,  but  are  the  result  of  specific  causes.  At  the 
present  time  certain  tumors  cannot  be  placed  definitel}'  among  either 
the  true  or  false  tumors.  To  this  group  belong  notabl}'  certain  affections 
of  the  lymph  glands. 

Since  we  are  unable  to  limit  our  conception  of  neoplasms  or  true 
tumors,  a  comprehensive  definition  even  for  this  relativel}'  narrow  group  is 

'  Die  Krankhaften  Geschwiilste.  Hirschwald,  Berlin,  1863,  vol.  i. 


18  THE  GENERAL  BIOLOGY  OF  TUMORS 

out  of  the  question.  At  present  any  attempt  to  confine  our  study  to  the 
true  tumors  will  defeat  its  own  purpose,  for  obviously  we  can  approach 
a  conception  of  the  neoplasms  onl}^  by  possessing  a  clear  notion  of  these 
false  tumors,  which  for  one  reason  or  another  have  been  excluded  from 
the  dignified  group  designated  as  neoplasms  or  true  tumors.  Theo- 
retically, most  pathologists  now  agree  that  an  autonomous  growth  of 
ceils  characterizes  true  tumors,  and  that  the  determmation  of  the  autono- 
mous character  of  any  given  group  of  cells  usually  implies  a  comparison 
with  cell  proliferations  not  autonomous,  such  as  hyperplastic  and 
reactive  processes  involving  those  regions  from  which  the  tumors  spring. 

It  would  seem,  therefore,  that  any  attempt  to  limit  the  discussion 
of  tumors  to  the  neoplasms  is  a  serious  handicap  to  a  clear  presentation 
of  the  subject,  and  that  Virchow  was  correct  in  grouping  together  all 
tumors  both  true  and  false.  From  the  clinical  point  of  view  this  is  the 
only  possible  method  of  approaching  a  proper  grasp  of  the  subject.  The 
clinician  must  parallel  the  development  of  our  knowledge  of  tumors  and 
in  a  sense  repeat  the  oncological  history,  just  as  a  comprehensive  under- 
standing of  anatom}'  requires  a  knowledge  of  embrA^ology.  The  first 
question  that  must  be  asked  in  approaching  a  tumor  problem  is,  "Is 
it  a  swelling,  or  is  it  an  enlargement  of  an  organ,  or  an  inflammation,  or 
a  congestion?"  Even  this  question  may  be  difficult  to  answer.  If  it 
is  a  tumor,  is  it  a  true  or  a  false  tumor?  Only  after  these  questions 
have  been  answered  is  one  ready  to  approach  the  problem.  Frequently, 
the  greatest  difficulty  is  experienced  in  answering  these  fundamental 
questions,  for  often  if  one  can  be  certain  that  the  enlargement  is  a  true 
tumor  the  problem  is  simple.  As  an  example  ma}'  be  cited  the  tumors 
of  the  testicle.  An  enlargement  may  be  due  to  a  hydrocele,  which  is 
an  exudate;  to  orchitis,  which  is  an  inflammatory  process;  to  syphilis 
or  tuberculosis,  which  are  granulomas;  or  to  a  teratoma,  which  is  a  devel- 
opmental anomaly.  Finally,  the  enlargement  ma}'  be  due  to  a  true 
tumor,  a  sarcoma,  or  a  carcinoma.  The  unnatural  limitation  of  the  dis- 
cussion to  the  true  tumors  is  due  in  large  part  to  the  disposition  of 
pathologists  in  the  past  to  limit  the  discussion  to  dead  tissue,  disregard- 
ing in  great  measure  the  living  manifestations  of  tumors  and  their 
relations   to  other  tissue  changes. 

In  the  following  discussion  the  broad  view  of  Virchow  will  be  followed 
and  all  tumors  will  be  included  which  might  reasonably  be  brought 
into  question  when  considering  neoplasms,  whether  it  be  by  clinical 
or  laboratory  study.  The  laboratory  student  of  oncology  has  as  many 
difficult  border-line  problems  as  has  the  clinician;  and,  indeed,  he  must 
often  ask  of  the  clinician  the  interpretation  of  the  pictures  revealed  in 
his  slides.  No  matter  how  skilled  the  microscopist,  the  nature  of  many 
tumors  can  be  determined  only  by  their  historj^  and  subsequent  course. 


cL./ss/j /(:.ir/(j.\  or  timors  \\\ 

Not  inhi'iiiKiit  l\  ,  intl;mim;if()i\  oi  t;i  ;iiHil(mi;i  i<iiis  |)i  oct-sscs  eannot  he 
ditterentiated  liom  s;in.-()m;i  cxrcpt  l)\  tlu-  lustorv  iiiul  coiiisc  ot  flu- 
(list^ase,  and  by  sonic  special  serological  or  therapeutic  test. 

This  Inroad  consideration  secnis  tin-  more  necessar}'  as  surgeons  i)econie 
more  tiamed  m  the  limdamental  medical  sciences  and  as  patholoj^ists 
grasp  Intter  the  kssons  to  he  learned  from  li\inti  patholop;}',  both  physio- 
logical and  anatomical;  for  it  is  only  by  the  study  of  all  phases  of  the 
subject,  histolouy,  histogenesis,  physiology,  course,  and  termination,  both 
of  true  and  false  tumors,  that  it  is  possible  to  gam  a  comprehensive  grasp 
of  the  meaning  of  the  term  "tumor"  in  its  broad  sense.  I  he  meaning  of 
cell  autonomy  can  be  grasped  only'  when  cell  proliferations  purposive 
in  character  are  fully  understood  as  manifest  under  the  most  diverse 
conditions.  When  so  studied,  a  conception  of  the  essential  nature  of 
the  tumor  {process  is  obtained,  and  while  the  student  is  still  unable  to 
define  a  tumor,  he  learns  what  is  infinitely  better,  wh}'  it  is  impossible 
to  do  so,  and,  what  is  even  more  important,  he  comprehends  the  direc- 
tion in  which  our  knowledge  must  be  extended  before  a  comprehensive 
definition  is  possible.  As  a  corollary  to  the  statement  of  Ribbert,  above 
quoted,  I  should  say-  we  are  able  to  understand  when  we  appl\'  this  broad 
method  of  investigation  why  we  cannot  conceive  the  tumor  problem  with 
sufficient  clearness  to  enable  us  to  define  it. 

CLASSIFICATION  OF  TUMORS 

In  the  consideration  of  tumors  it  is  necessary  to  employ'  some  kind  of 
working  classification.  The  simplest  plan  is  to  follow  the  classification  of 
the  elemental  tissues  employed  in  histology.  By  adhering  to  this  scheme 
in  designating  a  particular  type  of  tumor  it  is  only  necessary  to  add  the 
suflftx  "oma"  to  the  name  of  the  elemental  tissue  from  which  it  springs.' 
Thus  a  tumor  arising  from  an  overgrowth  of  fibrous  tissue  is  a  fibroma, 
one  from  bone  an  osteoma,  one  from  muscle  a  myoma,  etc.  In  addition 
to  this  histological  division,  a  clinical  classification  is  necessar\',  because 
some  tumors  tend  to  destroy  life  while  others  do  not.  The  former  class 
we  call  malignant,  the  latter  benign.  With  these  elementary  groups 
in  mind  we  are  able  to  recognize  and  group  all  that  is  known  of  the 
origin  and   pathology  of  tumors. 

The  following  classification,  adopted  with  modifications  from  Ribbert,- 
is  simple  and  as  satisfactory  as  any  yet  proposed: 

^  1  his  statement  can  have  but  a  general  apphcation,  for  in  man}'  tumors  the  tissue 
from  which  the}'  are  derived  cannot  be  determined  or  the  mother  tissue  does  not  con- 
form to  any  of  the  elemental  tissues,  as  those  from  developmental  anomalies.  In  such 
instances  they  must  be  classed  with  those  tumors  which  they  most  resemble. 

^  GeschwUlstlehre,  Cohen,  Bonn,  1904. 


20  THE  GENERAL  BIOLOGY  OF  TUMORS 

Connective-tissue  Group. — Fibromas,  derived  from  fibrous  tissue; 
lipomas,  derived  from  fatty  tissue;  chordomas,  derived  from  chorda  tissue; 
chondromas,  derived  from  cartilage;  osteomas,  derived  from  bone;  angio- 
mas, derived  from  bloodvessels;  sarcomas,  derived  from  connective  tissue, 
but  differing  from  it  in  being  composed  largel}"  of  cells  resembling  more 
or  less  embryonal  cells,  forming,  therefore,  an  atypical  connective  tissue. 
A  number  of  groups  of  sarcoma  may  be  distinguished: 

(a)  Simple,  which  are  derived  from  cells  common  to  all  connective 
tissue.  These  may  be  divided  according  to  their  cell  form — round  or 
spindle  celled. 

(b)  Lymphosarcoma,  or  lymphomas,  which  are  derived  from  cells 
resembling  leukocytes. 

(c)  Myxosarcomas,  derived  from  mucoid  tissue. 

(d)  Melanosarcomas,  or  melanomas,  derived  from  pigment  cells. 
Muscle-tissue  Group. — Rhabdomyomas,  derived  from  striated  muscle, 

and  leiomyomas,  derived  from  non-striated  muscle. 

Nerve-tissue  Group. —  Neuromas,  tumors  characterized  by  tissue 
resembling  nerves  and  ganglion  cells,  and  gliomas,  formed  from  glia 
cells. 

Epithelial-tissue  Group. — Papillomas,  fibro-epithelial  tumors  formed 
from  epithelial  and  fibrous  tissue,  and  carcinomas,  formed  of  inde- 
pendent epithelial  cells,  being  dependent  on  the  connective  tissue  only 
for  nutrition.     These  are  divided  into: 

(a)  Epithelioma,  derived  from  squamous  epithelium. 

(b)  Carcinoma,  derived  from  glandular  epithelium. 
Endotheliomas. — Endotheliomas   are   derived   from   endothelial   cells. 
Cysts. — Cysts  are  divided  into  (a)  proliferative,  those  with  actively 

developing  walls;  (b)  degenerative,  resulting  from  liquefaction  of  some 
portion  of  a  solid  tumor;  (c)  retentive,  due  to  the  closure  of  an  outlet 
duct. 

Teratomas  and  Mixed  Tumors. — The  teratomas  and  mixed  tumors 
are  developmental  anomalies,  subject,  however,  to  neoplastic  pro- 
cesses. 

Combinations  of  Tumors. — With  this  scheme  the  classification  is 
not  complete.  Certain  combinations  of  tumors  appear  which  require 
combined  names  for  their  designation.  As  examples  of  this  may  be 
mentioned  tumors  composed  of  cartilage  and  bone,  osteochondroma; 
muscle  and  fibrous  tissue,  fibromyomas.  A  compound  term  may  be 
applied  properly  only  when  more  than  one  type  of  tissue  is  active  and 
of  pathological  importance.  It  is  necessary  to  distinguish  elements 
which  arise  by  degeneration  in  preexisting  tumors  from  tumors  in  which 
such  elements  are  active  participants  in  the  tumor  formation.  Thus, 
a  myxomatous  degeneration  of  a  fibroid  must  be  distinguished  from  a 


STRCcn  ki:  or  ri  mors  _m 

myxofibroma.  Wlun  a  rissui-  is  atri\(.-  in  its  growth  and  yet  has  no 
^tiU'tic  parh()l()<i;ical  si^mficanci-,  a  conipoiiiul  term  is  not  applicable. 
I  luis,  in  stiiihous  cancel  rlu-  hbioiis  tissue  makes  \\\)  a  lai^e  part  of 
tlie  tumor,  \et  the  term  fibrocarciiK)ma  is  not  apphcable  because  the 
fibrous  tissue  does  not  develop  as  the  result  of  a  neoplastic  stimulus 
arisinp;  in  itself  but  in  response  to  the  stimulus  of  the  epithelial  cells. 
In  compound  terms  the  chief  tissue  is  made  the  noun,  while  the  lesser 
tissue  IS  exjiressed  by  the  adjecti\'e  prefix.  Thus  if  myx(jid  and  fibrous 
tissue  combine  to  form  a  tumor,  if  the  fibrous  elements  predominate 
the  proper  term  is  myxofibroma;  if  the  m\xoid  tissue  predominates, 
the  converse  would  be  the  proper  term.  Such  combinations  may  be 
added  to  an\'  of  those  named  above  as  subvaneties. 


STRUCTURE    OF   TUMORS 

All  tumors  are  made  up  of  cells  and  connective  tissue,  just  as  are 
the  normal  structures.  The  understanding  of  tumors  depends  upon 
the  study  of  the  properties  of  the  cells  or  parenchyma  on  one  hand 
and  the  connective  tissue  or  stroma  on  the  other,  and  upon  their  rela- 
tions to  each  other.  The  stroma  is  composed  of  connective  tissue  and 
bloodvessels  and  is  much  alike  in  all  classes  of  tumors,  differing  onl}' 
in  amount  and  arrangement.  It  is  the  parenchyma  that  marks  the 
chief  differentiation  in  the  structure  of  the  different  tumors.  This 
parenchyma  may  consist  of  am'  elemental  tissue,  such  as  connective 
tissue,  muscle,  cartilage,  nerve,  bone,  and  epithelium  of  all  kinds,  such 
as  stratified,  glandular,  etc. 

Parenchyma. — The  relation  and  arrangement  of  the  parenchyma 
vary  widely.  The  differences  from  the  normal  are  at  times  so  slight 
as  to  be  almost  indistinguishable,  and  at  other  times  so  great  as  hardly 
to  furnish  common  grounds  for  comparison.  The  close  relation  to  the 
normal  is  seen  in  the  tendenc\'  of  some  tumors  to  produce  cartilage, 
bone,  etc.  This  is  even  more  striking  in  the  disposition  of  some  of 
the  glandular  tumors  to  carr\'  on  the  function  of  the  mother  tissue. 
Thus,  the  function  of  the  thyroid  may  be  performed  by  the  tumors 
of  that  gland,  and  a  biliary  secretion  ma}'  be  produced  by  tumors  of 
the  liver.  This  is  even  more  clearh'  demonstrated  by  tumors  which 
may  largely  displace  certain  organs,  the  loss  of  whose  function  is 
attended  by  certain  constitutional  symptoms,  and  yet  the  symptoms 
ma\  not  appear.  For  example,  tumors  of  the  pancreas  ma\'  exist  with- 
out production  of  diabetes,  tumors  of  the  adrenals  without  production 
of  Addison's  disease.  Adenomas  produce  a  secretion  which  afl^ects 
the  organism  in  the  same  manner  as  an  overproduction  of  the  normal 
secretion,  causing,  for  instance,  exophthalmic  goitre  in  adenoma  of  the 


22  THE  GENERAL  BIOLOGY  OF   TUMORS 

thyroid.  Argument  from  cases  of  this  kmd  is  subject  to  many  fallacies, 
for  it  is  difficult  to  determine  whether  or  not  all  of  the  normal  gland 
tissue  has  been  replaced  by  the  tumor. 

On  the  other  hand,  the  deviation  from  the  normal  is  usually  marked. 
Often  the  transition  is  gradual,  each  successive  group  resembling  less 
and  less  the  mother  cells,  so  that  frequently  the  nature  of  the  cells  can 
be  judged  by  their  location  only.  Thus  the  cells  in  a  simple  carcinoma 
of  the  mamma  could  not  be  identified  as  derived  from  mammary  epi- 
thelium if  their  source  were  not  known.  This  is  particularly  true  in 
secondary  tumors.  The  metastases  often  bear  no  resemblance  to  the 
normal  tissue  from  which  the  mother  tumors  are  derived. 

Stroma. — The  stroma  of  tumors  ma}^  be  derived  from  one  or  both 
of  two  sources:  (i)  The  connective  tissue  and  bloodvessels  of  the 
tissue  invaded  by  the  growth  may  become  the  stroma  of  the  tumor; 
or  (2)  in  response  to  the  stimulus  of  the  parenchymal  cells  new  con- 
nective tissue  and  bloodvessels  may  be  formed;  or  more  frequently 
both  sources  may  contribute.  In  the  expansile  tumors,  where  the  entire 
growth  takes  place  within,  all  the  stroma  must  necessaril}^  be  newly 
formed.  When  an  infiltrating  tumor  invades  an  organ  the  connective 
tissue  of  the  region  invaded  may  be  converted  into  stroma  or  it  may 
be  destroyed.  Ordinarily  the  connective  tissue  remains,  and  m  response 
to  the  stimulus  of  the  parenchyma  cells  produces  additional  tissue. 
In  this  way  stroma  is  derived  from  both  sources.  In  addition  to  the 
production  of  new  stroma  the  irritation  of  the  parenchyma  cells  may 
produce  an  extensive  round-celled  infiltration.  This  may  become  so 
great  that  the  whole  stroma  seems  composed  of  granulation  tissue. 
In  .certain  tumors  the  stroma  may  be  stimulated  to  marked  growth. 
This  occurs  especially  in  bone.  In  certain  carcinomas,  when  they 
approach  bone,  the  latter  is  stimulated  to  the  production  of  new  tissue- 
forming  osteocarcinomas.  This  explanation  is  preferred  rather  than 
to  assume  that  any  connective  tissue  may  undergo  so  extensive  a  meta- 
morphosis as  to  produce  bone.  Certain  kinds  of  parenchymal  cells 
seem  to  have  a  peculiar  power  of  stimulating  to  proliferation  the  tissue 
invaded  while  others  seem  to  lack  it  entirely.  The  reaction  of  the 
connective  tissue  invaded  by  a  growth  may  be  so  great  as  to  overshadow 
in  large  part  the  real  pathological  process.  This  is  seen  particularly 
in  the  slowly  developing  carcinomas  with  much  connective-tissue 
formation,  e.  g.,  the  so-called  scirrhous  cancers.  This  fibrous-tissue 
formation  may  be  so  great  as  to  make  an  effective  reaction  against  the 
invasion  of  the  newgrowth,  thus  partially  confirming  the  statement  of 
some  authors  that  carcinoma  is  naturally  a  self-limited  disease  and 
that  the  connective-tissue  proliferation  is  a  conservative  process.  In 
apparent  harmony  with  this  supposition  these  tumors  are  often  more 


sTRi  cri  kJ:  or  rt  moms  2.'> 

r:ipicll\  t;ir;il  uluri  such  reaction  is  ahsciu.  This  is  onl)'  very  hroadi) 
riiif,  toi  ruiiiois  possissid  ot  nuicli  stroma  ma\  metastasize  earl\'  and 
recur  with  pii  sisteiice.  I  he  character  as  well  as  tht-  amount  ot  con- 
nective tissue  seems  to  be  a  tactor.  On  the  other  hand,  some  tumors 
j^rovv  so  rapidly  that  such  reaction  does  not  manifest  itself,  possibly 
because  the  tissue  is  overwhelmed  by  toxic  products.  Ibis  is  similar 
to  what  takes  place  in  severe  infections  where  in  place  of  the  leulco- 
c\tosis  ordinariI\'  expected  there  is  a  definite  leukopenia. 

Bloodvessels.  I  umors  have  a  complete  vascular  circulation,  as  was 
first  pointed  out  by  J.  Miiller.  The  arteries  and  veins  with  their  con- 
necting capillaries  ma\'  be  demonstrated  b\'  injection.  The  sizes  of 
the  vessels  vary  more  than  in  the  normal.  F^ither  set  of  vessels  ma\' 
predominate  throughout  the  entire  tumor  or  in  special  parts.  T  he 
bloodvessels  within  a  tumor  ma\'  be  either  native  to  the  region  or 
newly  formed.  The  first  kind  are  found  in  the  infiltrating  tumors  only. 
The  expansile  tumors  have  newly  formed  vessels  only,  and,  therefore, 
the  larger  the  tumor  the  farther  removed  are  the  vessels  from  their  base 
of  supply.  For  this  reason  the  centres  of  expansile  tumors  are  poorly 
nourished  and  are  frequently'  subject  to  degeneration  from  lack  of 
nutrition.  The  vessels  are  formed  by  budding,  and  their  number 
depends  upon  local  conditions,  largeh'  but  not  entirely  upon  the  nature 
of  the  tissue  in  which  the  tumor  occurs.  The  newly  formed  vessels, 
like  the  tumor  cells,  depart  somewhat  from  the  normal.  They  do  not 
possess  the  coats  of  normal  vessels,  but  are  formed  of  an  endothelial 
lining,  and  at  most  a  fibrous-tissue  layer.  They  vary  in  size  greatly 
and  somewhat  abruptly;  they  may  form  sinuses  which  when  connected 
with  large  vessels  ma\'  give  the  sense  of  pulsation.  In  some  of  the 
more  rapidly  growing  tumors,  notabl\-  sarcoma,  the  vessel  walls  within 
the  tumor,  both  native  and  newh'  formed,  are  subject  to  the  various 
degenerations  common  to  vessels  elsewhere,  which  may  lead  to  rupture 
or  thrombosis. 

Nerves. • — Nerves  have  not  been  satisfactorily  demonstrated  as  grow- 
ing in  expansile  tumors,  a  fact  which  their  painless  clinical  course,  both 
in  growth  and  in  degeneration,  confirms.  Infiltrating  tumors  may 
develop  about  and  include  the  nerves  native  to  the  parts  affected,  a 
fact  which  is  attested  by  the  severe  pain  often  attending  them. 

Lymphatics. — Lymph  channels  have  not  been  demonstrated  within 
expansile  tumors.  The  frequent  formation  of  metastases  by  these 
channels  make  their  existence  probable  in  infiltrating  tumors,  but  most 
pathologists  deny  the  new  formation  of  lymphatics.  There  is  much 
difference  of  opinion  on  this  point,  and  a  reinvestigation  ot  the  subject 
is  much  needed. 

^  ^'oung.  Jour.  Exper.  Med.,  1897,  ii,  i. 


24  THE  GENERAL  BIOLOGY  OF  TUMORS 


GROWTH    OF   TUMORS 

Benign  tumors,  because  of  their  slow  growth  and  their  resemblance 
to  the  normal,  are  unsuited  for  the  study  of  the  details  of  growth.  There- 
fore the  growth  of  tumors  has  been  studied  chiefly  in  small  epitheliomas 
or  in  the  advancing  border  of  further  developed  carcinomas  of  the 
same  type. 

When  it  was  first  demonstrated  by  Thiersch^  and  Waldeyer^  that 
all  carcinomas  develop  from  epithelium,  it  was  assumed  that  the 
neighboring  normal  cells  become  carcinomatous  by  contact  with  the 
malignant  cells.  This  was  called  growth  by  apposition.  Some  pathol- 
ogists believe  that  new  independent  foci  of  development  are  formed 
in  the  neighborhood  of  the  original  tumors,  and  that  these  foci  coalesce 
(Hansemann,  Lubarsch).  This  has  been  called  multicentric  growth. 
Evidence  has  accumulated  in  recent  years  which  has  gone  far  to  sub- 
stantiate these  earlier  observations.  In  many  carcinomas  the  cells 
adjacent  to  cell  nests  show  alteration  in  structure.  This  is  seen  par- 
ticularly well  in  intestinal  growths  in  which  the  changes  in  the  glands 
gradually  shade  off  into  the  normal,  as  if  some  stimulus  were  causing 
successive  glands  to  undergo  abnormal  proliferation,  the  changes  being 
the  less  marked  the  further  removed  the  glands  are  from  the  source 
of  stimulation.  The  same  is  frequently  seen  in  the  skin  epitheliomas. 
In  transplanted  epithelial  tumors  in  animals  the  connective  tissue 
has  been  stimulated  to  sarcoma  formation,  showing  that  the  power 
to  grow  ma}^  be  transmitted  to  other  kinds  of  tissue.  Still  more  con- 
clusive are  the  experiments  of  Borrel  and  Lewin  in  which  epidermis 
was  stimulated  to  the  formation  of  squamous  epithelioma  by  the  trans- 
plantation of  a  glandular  tumor  beneath  it,  showing  that  proliferating 
stimulus  may  be  conveyed  by  cells  possessed  of  the  power  of  unlimited 
growth.  In  both  these  instances  there  could  be  no  confusion  between  the 
normal  and  the  tumor  cells.  The  proliferation  excited  by  Scharlach  R 
and  Sudan  III  likewise  show  clearly  that  epithelial  cells  can  be  made 
to  proliferate  and  invade  surrounding  tissue  by  the  action  of  certain 
extrinsic  stimuli.  It  may  be  regarded  as  proved,  therefore,  that  nor- 
mal epithelial  cells  under  certain  conditions  may  be  made  to  proliferate 
by  close  contact  with  malignant  cells  or  by  other  stimuli. 

Nevertheless,  Ribberf^  is  unquestionably  right  when  he  maintains 
that  most  tumors,  particularly  epitheliomas,  begin  at  a  certain  point 


'^  Der  Epithelkrebs,  Leipzig,  1865. 

"  Ueber  den  Krebs,  Sammlung  klin.  Vortr.,  No.  33,  Breitkopf  &  Haertel,  Leipzig,  1872. 
Die  Entstehung  des  Carcinoms,  Cohen,  Bonn,  1906. 


V.ROII  III  oi    11  MORS  25 

(ti^.  I)  ami  j;n)\\  out  ti<»m  tins  point  like  tin-  biaiKlits  (W  a  tree-  ( uni- 
centnc  i;ro\\rh).  As  tlu  tuinoi  cUxilops  these-  hiaiiches  extend  farther 
and  laitlui  nuo  rlu-  surrounding  tissue  until  some  of  the  branches 
approach  the  surface  epithelium  at  a  distance  I'lom  the  original  focus, 
and  may  appear  to  he  derived  from  the  epithelium  at  this  |)oint,  while 

Fic.  I 


Schematic  drawing  of  a    beginning  epithelioma,  showing   normal   epithelium   and 
beginning  abnormal  proliferation. 

in  fact  they  are  developed  from  the  original  focus  (Fig.  2).  B\-  the 
continued  extension  of  these  branches  the  surface  epithelium  is  destro\ed 
(Fig.  3).  Serial  sections  and  reconstructions  have  shown  this  to  be 
true  in  the  great  majority  of  tumors,  and  it  is  now  generall\-  believed 
to  be  the  usual  manner  of  growth  for  the  more  simple  t\pe  of  epithelial 


Fig.  2 


=rr 


'■^i^^V>-i^ 


r:C 


m^ 


y.  (f 


#- 


Conrmuation  of  Fig.  i,  showing  cell  columns  approaching  the  normal  epithelium. 

tumors.  Cells  multiplying  from  a  single  centre  occupy  the  line  of 
least  resistance,  which  is  usually  the  connective-tissue  spaces.  Cells 
passing  into  these  tissue  spaces  give  rise  to  new  foci  which  appear  at 
some  distance  beyond  the  advancing  cell  column  and  which  may  later 
coalesce  with   the  mother  tumor  instead  of  being  a  distinct  continuous 


26  THE  GENERAL  BIOLOGY  OF  TUMORS 

outgrowth  from  the  primary  focus.  These  new  foci  must  be  distin- 
guished from  multicentric  growths  in  which  new  foci  arise  independently 
of  the  original  tumor.  These  foci  in  the  tissue  spaces  may  be  seen  in 
many   tumors.      There   is   no   question,   however,    but   that   these   cells 

Fig.  3 


T^'^^j-i  - 


By  extension  of  the  branches  shown  in  Fig.  2,  the  surface  is  destroyed,  producing 

an  ulcer. 

have  escaped  from  the  mother  tumor  and  are  not  normal  cells  which 
have  become  cancerous  in  that  situation  from  contact  with  other  tumor 
cells  or  have  arisen  independently. 

The  development  of  other  tumors  has  been  studied  but  little,  because 
the  point  of  origin  is  difficult  to  determine.     The  benign  tumors  also 

Fig.  4  Fig.  5 


X 


Schematic  drawing  of  a  beginning  Continuation  of  Fig.  4.     The  develop- 

tumor.  ing  cells  have  pushed  aside  the  connective 

tissue  forming  a  capsule. 

probably  begin  at  a  single  focus,  and  the  development  proceeds  from  this 
point.  Sarcomas  probably  follow  the  same  course,  but  in  them  the 
problem  is  more  difficult,  for  very  small  sarcomas  are  not  presented  for 
examination  and  the  advancing  border  cannot  be  certainly  identified  at 


MKT.isr./s/s 


27 


sucli  ;iM  c;iil\  sr;i^f  hccaust-  ot  tin-  rcscnihlanci-  to  \()unj;  coiiiu-ctive- 
tissLic  ami  ^laiuilation-tissue  cells.  In  sarcomas  developing  in  henior- 
rhaj^ic  degeneration  ot  niyonias  ot  tlu-  iittius  the  malignant  process 
htgins  about  tin-  entire  peripluiy  of  the  lieiiiorrhagic  mass.  In  carci- 
nomas ot  tin  lactating  breast  many  areas  seem  simultaneousK'  to  take 
on  a  maliti,nant  liiowtii. 

Hegmmnii  at  a  single  point  (  Kig.  4),  tumors  in  their  mode  of  develop- 
nunt  follow  one  of  two  types  that  can  usualh'  he  distinguished  the 
expansile  and  the  inHltratmg. 

Expansile  Tumors.  In  then  dexelopnunr  the  expansile  tumors 
press  aside  the  surrounding  tissue.  In  this  wa\'  a  so-called  capsule 
IS  formed  hy  the  condensed  displaced  tissue  (Fig.  5).  The  tumor  is 
enclosed  in  this  capsule  and  can  be  readily  shelled  out.  The  tumor 
cells,  in  other  words,  possess  the  power  of  autonomous  growth,  but  not 
of  in\ading  the  surrounding  tissue. 

Infiltrating  Tumors.  -In  contradistinction  to  the  foregoing,  while 
they  begin  at  a  single  point,  as  do  the  expansile  type,  the  cells  pass  out 
into  the  interstices  of  the  connective  tissue  'Fig.  6)  like  the  roots  of 
a  plant  into  the  soil.  Longer  or  shorter 
columns  of  cells  may  be  followed  extend- 
ing from  the  mother  tumor  into  the 
surrounding  tissue.  In  this  class  no 
capsule  is  formed.  The  connective 
tissue  and  the  contained  vessels  and 
nerves  of  the  tissue  invaded  become  a 
part  of  the  tumor  or  are  destroyed. 
In  certain  rapidl}'  growing  infiltrating 
tumors,  however,  the  expansile  growth 
is  simulated,  the  surrounding  tissue 
being  pushed  apart  at  the  circumference 
of  the  tumor.  This  gives  rise  to  a 
pseudo-encapsulation,  but  the  restraint 
ordinaril}'  imposed  b}'  the  capsule  of 
the  surrounding  tissue,  as  observed  in 
the    expansile    t\'pe,  is     lacking.      This 

type,  in  contradistinction  to  the  preceding  type,  possesses  not  only 
the  powder  of  autonomous  growth,  but  that  of  invading  the  surrounding 
tissue  as  w^ell. 


Fig.  6 


« 


# 


Continuation  of  process  in  Fig.  4. 
Instead  of  pushing  tissue  aside,  as 
in  Fig.  5,  the  cells  have  passed  into 
the  tissue  spaces. 


METASTASIS 

W  ith  the  escape  of  the  cells  into  the  interstices  of  the  normal  tissue 
numerous  modifications  in  growth  are  possible. 

Cells   growing   from    the   peripher\'   of  malignant   tumors   invade   the 


28  THE  GENERAL  BIOLOGY  OF  TUMORS 

surrounding  connective-tissue  spaces,  usually  maintaining  connection 
with  the  tumor.  Frequently  cells  are  found  lying  singly  in  the  tissue 
clefts.  Not  infrequently  cells  escape  to  greater  distances  into  the 
connective  tissue  and  begin  to  proliferate,  or  they  may  escape  into  the 
lymph  vessels  and  proliferate  in  neighboring  lymph  glands,  or  they 
may  be  carried  by  the  bloodvessels  to  remote  parts  of  the  body.  When 
developing  in  the  region  of  the  tumor  they  are  called  local  metastases, 
when  in  the  neighboring  lymph  glands  they  are  called  regional  meta- 
stases, and  when  in  distant  parts  they  are  called  remote  metastases. 
Local  Metastasis. — The  dividing  line  between  local  metastasis  and 
infiltrative  growth  is  not  sharp.  When  cells  form  perceptible  nodules 
in  the  region  of  the  mother  tumor,  local  metastasis  may  be  said  to  occur. 
Usually  these  local  nodules  result  from  extension  into  the  connective- 
tissue  spaces.  Their  direction  is  independent  of  the  lymph  current, 
though  development  along  lymph  channels  cannot  be  disproved. 
The  extent  to  which  local  metastases  take  place  varies.  They  are 
most  often  noted  in  the  skin,  mucous  and  particularly  serous  surfaces. 
They  usually  indicate  an  active  proliferation  of  the  tumor  cells  and 
a  corresponding  hopeless  prognosis.  After  the  removal  of  the  primary 
tumor  multiple  nodules  often  develop  in  the  site  of  the  original  tumor. 
This  is  seen  with  particular  frequency  after  breast  amputation  for 
carcinoma.  Such  multiple  nodules  may  develop  in  the  presence  of 
the  primary  tumor  (see  carcmoma  en  cuirasse). 

Fig.  7 


C 


h 


Extension  of  carcinoma  cells  into  a  lymph  channel:     a,  nest  of  carcinoma  cells; 
b,  wall  of  lymph  channel;  c,  connective  tissue. 

Regional  Metastases. — Cells  gaining  access  to  the  Ij/^mph  channels 
(Fig.  7)  are  transplanted  to  regional  lymph  nodes  and  there  develop. 
Usually  the  glands  affected  are  proximal  to  the  region  of  the  primary 
disease.     Cells  may  be  stopped  in  the  course  of  the  vessels  and  form 


MKT./sr.lSIS  29 

iioilulis,  (»i  (.aiuH  I  (.tils  iii.i\  (l«\clop  l)\  coiHiiHiiry  alon^  the  nirirc- 
1\  nipli  (.Ikiiii  I\  in|ili;inL;it  is  cai  (.iiioiiki  tosa).  1  his  is  partu-iihirl)' 
likcl\  to  ocelli  m  ilu  |iUiiial  ami  otluT  serous  cavities.  I  he  chsposi- 
tion  ot  the  C(.lls  to  locah/c  iii  the  nei^liliorin^;  lymph  glands  make  it 
possible  to  piitliet  tin-  location  of  such  metastases  and  to  anticipate 
rluiii  In  rcmo\al  of  tin-  i;laiuls  at  o|Hration.  1  his  tact  is  made  the 
basis  tor  modern  operations.  ( )ccasionally  the  tirst  j^roiip  is  skij^ped 
and  oiH-  ot  the  next  m  succession  is  iinolved.  1  he  reason  tor  this  is 
not  deal",  hut  it  has  been  held  that  tin-  cells  jiass  through  the  tirst  ^roup 
of  glands  and  become  lodged  in  a  second  group.  It  is  nujie  probable 
that  channels  pass  from  the  site  of  carcinoma  directl\'  to  the  second 
group  of  glands.  \\  hen  the  primar\  glands  are  aftected  these  in  turn 
may  form  toci  for  cells  which  in\ade  more  remote  groups  of  glands. 
Carcinomas  usually  choose  this  method  of  dissemination. 

Fig.  8 


t^-JL'. V* ">'•'. v'"V.*'''"i  •.'  '•."*"'♦*;■»'» ■'•it',  ,':^'.''', 

Carcinoma  growing  into  a  bloodvessel:     a,  carcinoma  cells;  b,  bloodvessel; 
c,  connective  tissue  with  round-celled  infiltration. 

Remote  Metastasis  (Systemic  Metastasis). — This  form  is  caused 
by  dissemination  through  the  bloodvessels.  Tumor  cells  invade  the 
vessels  (Fig.  8)  and  are  then  transported  to  some  point  impervious 
to  them.  The  veins,  because  of  their  thinner  walls,  are  most  frequenth' 
invaded,  though  the  arteries  at  the  base  of  the  heart  may  also  be  attacked. 
Sarcomas  usually  metastasize  in  this  manner,  but  carcinomas  sometimes 
do  so.  General  metastasis  may  take  place  by  extension  of  the  growth 
into  the  thoracic  duct.  When  tumors  spread  through  the  blood  stream 
or  the  thoracic  duct  an}'  region  of  the  body  irrespective  of  the  situa- 
tion of  the  tumor  ma}'  be  invaded. 

Retrograde  Metastasis. — Besides  these  three  common  methods  of 
metastasis,  tumors  ma}'  spread  by  extension  into  veins  in  the  direction 
opposite  to  the  blood  current.  This  is  called  retrograde  metastasis.  This 
ma\'  be  explained  in  some  instances  perhaps  b\'  a  temporar\'  reversal  of 


30  THE  GENERAL  BIOLOGY  OF  TUMORS 

the  blood  stream,  but  usually  it  is  a  direct  extension  along  the  blood 
channels.  This  is  seen  most  often  in  the  region  of  the  kidney  and  about 
the  uterus.  Not  mfrequently  extension  takes  place  upon  serous  surfaces. 
It  is  assumed  that  cells  escapmg  from  the  parent  tumor  are  propelled 
by  the  movements  of  the  abdommal  or  thoracic  organs  to  remote  parts 
of  the  cavity  and  there  become  attached.  There  is  evidence  that  this 
takes  place  because  in  certain  papillomas  of  the  ovary  tumors  extend 
directly  from  the  ovarian  tumor  to  the  peritoneal  surfaces.  The  more 
remote  situations  of  such  nodules  make  it  appear  probable  that  these 
have  become  transplanted  m  the  same  way.  These  lie  above  and  invade 
the  peritoneum.  In  a  large  number  of  cases,  nodules  generally  assumed 
to  have  been  transported  in  this  manner  are  seen  on  section  to  he 
beneath  the  peritoneum  and  must  have  reached  their  location  by  some 
channel  lying  beneath  this  membrane. 

Extension  by  Contact. — Much  controversy  has  arisen  about  the 
possibility  of  so-called  contact  transplantation.  In  the  ovarian  papil- 
lomas, already  mentioned,  transmission  by  direct  contact  seems  cer- 
tain. In  the  removal  of  these  tumors  fragments  broken  off  and  lodged 
in  the  abdominal  wound  ma)^  give  rise  to  similar  tumors  years  after 
the  primary  operation.  Whether  a  cancer  situated  on  one  surface 
may  excite  a  like  tumor  on  an  opposing  surface  is  more  doubtful.  It 
seems  plausible  that  the  primary  tumor  may  produce,  first,  a  destruc- 
tion of  the  covering  epithelium,  and  then  an  implantation  of  the  tumor 
cells  or  an  excitation  of  the  normal  cells  to  multiplication.  Instances 
are  on  record,  particularly  about  the  vagina  and  perhaps  the  lip,  which 
compel  one  to  admit  the  possibility  of  such  transplantation.  But  when 
cells  from  the  pelvis  of  the  kidney  are  said  to  pass  down  the  ureters 
and  become  implanted  in  the  bladder,  or  from  the  mouth  down  the 
esophagus,  and  produce  tumors  in  the  stomach,  we  must  protest.  As 
Ribbert  states,  to  assume  that  cells  capable  of  further  growth  might 
escape  from  the  ulcerated  surface  of  a  carcinoma  and  withstand  the 
action  of  the  gastric  juice  to  find  an  eroded  spot  upon  which  to  alight 
and  propagate  surpasses  credulity.  It  is  more  reasonable  to  admit  the 
extension  by  vascular  or  lymphatic  channels  or  simultaneous  multiple 
origin. 

Laws  Controlling  Metastases. — That  cells  are  able  to  maintain  an 
existence  independent  of  the  parent  tumor  is  the  strongest  argument 
for  the  autonomy  of  the  cell  growth.  That  the  cells  themselves  are 
the  origin  of  the  developing  metastasis  needs  only  the  argument  of 
the  similarity  or  even  the  identity  of  cells.  When  cells  in  metastases 
do  differ  from  those  of  the  parent  tumor,  the  difference  is  only  one  of 
degree;  usually  the  change  is  one  of  a  lessened  differentiation.  Why 
cells  from  certain  tumors  have  the  power  of  developing  at  a  distance, 


M/rr.tsT.is/s  M 

why  soiiu-  tlo  so  early  ami  orlu-is  late-,  is  clt[Hiiciiiit  upou  rlu-  same 
factors  rhar  make-  ir  possible  tor  some  cells  to  iii\acle  the  surroundinji 
tissue  while  others  do  not.  it  is  not  a  satisfactory  explanation  to  sa\ 
that  some  have  greater  independence  of  growth  than  others,  hut  noth- 
ing more  definite  can  be  stated  regarding  it.  It  is  of  interest  to  note 
that  cells  w  hich  once  gain  access  to  the  general  circulation  do  not  develop 
indifferently  in  an\'  region  of  the  body,  but  do  so  in  particular  organs. 
1  hose  extending  by  way  of  the  l\  niphatics  lodge  where  the  lumen 
becomes  too  small  to  permit  their  passage,  and  they  develop  there  or 
perish.  When  they  gain  access  to  the  circulation,  other  factors  must 
operate.  The  liver  and  lung  are  the  favorite  seats,  though  the  bone 
marrow  is  the  site  of  election  for  certain  tumors.  Muscle  is  peculiarh' 
immune  from  all  classes  of  tumors.  Clearly  these  organs  of  predilec- 
tion must  possess  conditions  favorable  for  the  developrnent  of  tumor 
cells,  and  those  immune  must  possess  some  element  of  protection  against 
them.  If  we  assume  with  Ribbert  that  all  organs  receive  a  like  number 
of  cells,  then  those  must  perish  which  lodge  in  organs  other  than  those 
in  which  they  are  known  to  develop.  To  what  extent  cells  are  destro\ed 
IS  but  idle  speculation.  Of  greater  practical  interest  but  equalh'  obscure 
IS  the  fact  that  cells  apparently  lie  dormant  for  many  years  after  the 
removal  of  a  tumor  and  then  develop.  That  these  late  recurrences 
are  due  to  the  production  of  a  second  primary  tumor  cannot  be  main- 
tained, for  the  new  tumor  may  resemble  the  original  one  histologically 
The  latency  of  these  cells  may  be  influenced  b\'  the  removal  of  the 
primar\'  tumor,  the  bod\'  being  able  for  a  long  time  to  hold  in  check 
the  remaining  cells.  This  must  be  admitted  as  a  possibility,  for  in 
tumors  of  limited  malignancy,  as  ovarian  papillomas  and  some  s\"nc^■ti- 
omas,  nodules  not  removed  at  the  time  of  the  removal  of  the  primar\' 
tumor  may  regress.  W  hat  influence  the  removal  of  the  primary  tumor 
will  have  on  the  existence  of  inaccessible  metastases  cannot  be  predicted. 
Metastasis  of  Benign  Tumors.' — Occasionall}"  tumors  believed  to 
be  benign,  usually  of  the  suprarenal  and  thyroid  glands,  form  meta- 
stases, most  often  by  wa\'  of  the  blood  channels.  The  new  tumors 
may  take  on  rapid  grow^th.  The  question  of  interest  is  whether  or 
not  these  conditions  should  be  called  benign.  If  the  cells  of  the  organ 
from  which  the\'  come,  whether  obviously  the  seat  of  tumor  forma- 
tion or  not,  have  the  power  of  invading  the  vessel  walls,  they  thereb\' 
show  a  certain  even  if  limited  degree  of  autonomy  and  declare  their 
malignancy.  In  cases  in  which  such  cells  are  believed  to  have  escaped 
from  normal  organs,  regions  of  malignancy  could  undoubtedly  be 
found  if  the  organ  were  subjected  to  a  complete  microscopic  examina- 

^  Borrmann,  Beitr.  z.  path.  Anat.  u.  z.  allg.  Path.,  1906,  xl,  372. 


32  THE  GENERAL  BIOLOGY  OF  TUMORS 

tion.  It  IS  just  these  organs,  the  thyroid  and  suprarenal  glands,  which, 
even  when  the  site  of  frank  tumor  formation,  exhibit  but  slight  changes 
from  the  normal. 

RECURRENCE 

By  recurrence  is  meant  the  reappearance  of  a  similar  growth  in  the 
region  of  the  primar}^  tumor  after  removal.  Cells  which  have  travelled 
to  a  distance  from  the  mother  tumor  may  easily  escape  the  surgeon's 
knife  and  afterward  develop  at  the  site  of  the  extirpated  tumor.  The 
recurrence  usually  resembles  the  tumor  extirpated  and  not  the  cells 
of  the  region  where  the  recurrence  takes  place.  The  fact  that  cells  may 
thus  he  dormant  many  years  has  caused  much  controversy.  The  recur- 
rence may  take  place  in  a  few  months,  and  usually  does  so  within  one 
to  several  years,  but  instances  are  on  record  where  twelve  or  more 
years  have  elapsed  between  the  removal  of  the  primary  tumor  and 
the  appearance  of  a  recurrence. 

In  some  mstances  recurrence  does  not  take  place  so  long  as  the  nutri- 
tion is  maintained  at  a  high  degree,  but  when  resistance  is  lowered  the 
tumor  develops.  The  influence  of  nutrition  on  recurrence  is  exemplified 
in  a  case  observed  b}^  Perkins.^  In  a  face  carcinoma  recurrence  took 
place  m  a  plastic  flap  from  the  neck,  while  the  skm  of  the  face 
surrounding  the  site  of  the  growth  remained  free  from  recurrence. 
Recurrence  must  be  distinguished  from  multiple  origin  whether  simul- 
taneous or  successive.  In  epitheliomas  of  the  face  (which  see)  it  is 
not  uncommon  to  see  independent  tumors  spring  up  m  various  parts 
of  the  face. 

Immunity. — Closel}^  associated  with  the  question  of  recurrence  is 
the  problem  of  the  natural  defence  of  the  body  against  the  aberrant 
tissue.  It  has  long  been  noted  by  clinicians  that  certain  tumors — 
chiefly  secondary  nodules  on  the  peritoneum,  ovarian  cystoma,  and 
metastatic  nodules  in  syncytioma — disappear  after  the  chief  mass  of 
the  tumor  has  been  removed.  The  natural  assumption  is  that  the 
organism,  being  freed  from  the  greater  portion  of  the  newgrowth,  is 
able  successfully  to  resist  the  small  remaining  portion.  The  predilec- 
tion of  metastases  for  certain  regions,  such  as  the  liver  and  lungs,  and 
the  antipathy  to  other  tissue,  notably  the  striated  muscle,  indicates 
a  resistance  in  some  tissues  not  possessed  by  others. 

This  problem  has  been  the  subject  of  a  vast  amount  of  experimental 
study,  with  the  result  that  it  has  been  demonstrated  that  immunity 
to  certain  strains  of  tumors  may  be  produced  in  animals.  The  exact 
nature  of  this  reaction  has  not  been  determined. 

^  Personal  communication. 


'/■///•;  Ei'iEcr  ().\  rill,  (.em-.k.ii.  (:o\srrn  tkjx  -V-i 


FORMS    OF    TUMORS 

!•  11)111  rlu'  foiciioiiiji,  It  may  be  tlccliiccil  that  tumors  assume  a  \aiicty 
of  forms.  I  lu-  expansile  tumors  naturally  are  globular  when  not  sub- 
jected to  uneciual  pressure.  The  infiltrating  growths,  on  the  other 
hand,  are  \ery  inejiular  in  form,  sometimes  failing  in  actual  tumor 
formation,  producing  instead  an  ulcerating  process.  If  an  expansile 
tumor  meets  resistance  to  its  growth  m  any  particular  direction,  it  con- 
forms to  the  shape  of  the  resisting  body;  for  instance,  a  lipoma  growing 
in  the  hilum  of  the  kidney  assumes  the  form  of  that  cavity.  On  the 
other  hand,  an  infiltrating  tumor  or  its  metastases  ma\'  present  a 
globular  form  when  growing  in  tissue  offering  equal  resistance  on  all 
sides.  The  form  of  the  organ  is  maintained  when  resistance  is  offered 
b\'  the  capsule  of  the  organ;  for  instance,  tumors  of  the  spleen  or  kidney 
often  retain  the  form  of  these  organs.  Ordinarih',  however,  infiltrat- 
ing tumors  form  irregular  masses,  extending  along  the  lines  of  least 
resistance.  The  irregularity  in  the  outline  of  the  tumor  ma\"  be  much 
increased  when  local  metastases  take  place,  forming  nodules  about  the 
border  of  the  tumor.  It  is  evident  that  growing  tumors  will  react  on 
surrounding  tissue  with  varying  results.  The  expansile  type  exerts 
a  mechanical  effect;  it  displaces  the  surrounding  tissue,  and  the  result 
depends  entirely  upon  the  size  of  the  tumor  and  the  nature  of  the  invaded 
tissue.  An  enormous  lipoma  of  the  subcutaneous  tissue  ma\'  cause  only 
inconvenience  from  its  weight,  while  a  small  intradural  fibroma  may  lead 
to  destruction  of  the  cord  hv  pressure.  The  infiltrating  growths,  on  the 
other  hand,  lead  to  local  destruction  of  tissue  both  from  pressure  and 
from  some  obscure  biological  property  of  the  malignant  cells. 

THE    EFFECT    ON    THE    GENERAL   CONSTITUTION' 

1  he  eftect  ma}'  be  direct  from  the  metabolism  of  the  tumor  or  second- 
ary from  interference  with  nutritive  processes.  The  exact  cause  of 
this  deleterious  effect  on  general  nutrition  has  not  been  fully  deter- 
mined. It  takes  place  chiefly  in  carcinomas.  The  amount  of  involvement 
of  tissue  is  not  always  in  proportion  to  the  effect  produced.  There 
ma}-  be  constitutional  s3'mptoms  when  the  tumor  is  small  and  not  the 
site  of  an\'  secondar}"  degenerative  processes,  and  it  may  be  absent  in 
the  presence  of  large  tumors.  This  has  given  rise  to  the  supposition 
that  some  metabolic  activity  of  the  cell  is  the  active  factor.  W  hen 
degenerative    changes    take    place    other    factors   enter.      Shutting    off 

'  For  literature  see  Lewin,  Die  bosartigen  Geschwiilste,  Kleinkliardr,  Leipzig,  1909. 
3 


34  THE  GENERAL  BIOLOGY  OF  TUMORS 

the  nutrition  of  the  tumor  may  produce  a  sudden  mtoxication  from 
necrosis  of  portions  of  the  tumor.  Secondary  bacterial  infection  may 
add  to  the  general  effect  of  the  intoxication  of  the  necrosed  tissue  those 
of  a  specific  infective  process.  The  effect  from  the  metabolic  process 
alone  produces  a  general  anemia,  loss  of  weight,  and  a  peculiar  bronz- 
ing of  the  skin.  This  symptom  complex  is  known  as  cachexia.  It 
is  not  present  in  all  tumors  and  is  variable  in  its  time  of  onset  and  its 
intensity,  and  may  be  produced  by  other  diseases.  Benign  and  more 
expansile  tumors  are  not  attended  by  such  constitutional  effects  un- 
less there  are  secondary  changes  or  some  interference  with  nutritive 
processes. 

Toxins. — The  presence  or  absence  of  a  specific  toxic  product  asso- 
ciated with  cancer  has  been  much  discussed.  Some  investigators  claim 
to  have  isolated  such  substances.  A  hemolytic  extract  or  enzyme  was 
isolated  by  Micheli  and  Donati^  which  they  believed  to  be  specific. 
It  is  generally  believed  that  there  is  a  difference  in  the  biochemical 
properties  of  tumor  cells,  but  Lewin  energetically  denies  that  these 
are  specific.  Carcinoma  cells  are  resistant  to  pepsin  but  sensitive  to 
trypsin.  Whether  these  changes  in  cell  chemistry  are  the  cause  or 
the  result  of  the  disease  has  not  been  demonstrated 

Blood. — The  blood  changes  in  tumors  vary  greatly.  Benign  tumors 
are  not  accompanied  by  any  change.  In  the  malignant  types,  partic- 
ularly in  carcinomas,  a  secondary  anemia  develops  sooner  or  later, 
but  it  possesses  no  specific  characteristics.  In  general,  the  blood  changes 
are  parallel  with  the  degree  of  disturbance  of  nutrition.  In  some  cases, 
particularly  in  carcinoma  of  the  stomach,  a  picture  closely  resembling 
that  of  pernicious  anemia  is  found.  The  red  cells  may  be  reduced  to 
a  million  or  less.  These  low  counts  have  been  noted  particularly  in 
carcinoma,  but  are  sometimes  observed  in  sarcoma.  Poikilocytes, 
microcytes,  and  macrocytes  are  often  present.  Small  nucleated  red 
cells  are  often  observed,  but  megaloblasts  are  rarely  present.  High 
hemoglobin  percentages  are  observed  when  for  any  reason  fluid  is 
abstracted  from  the  blood  or  fluid  cannot  be  taken  ie.  g.,  carcinoma  of 
the  esophagus).  Leukocytosis  may  be  present  in  both  sarcoma  and 
carcinoma.  In  carcinoma  the  increase  in  the  white  cells  is  moderate 
in  degree,  rarely  exceeding  12,000  unless  there  is  an  inflammatory  com- 
plication. Sarcomas,  on  the  other  hand,  are  often  attended  by  leuko- 
cytic increase,  reaching  not  infrequently  30,000  or  40,000.  Virchow 
regarded  the  occurrence  of  increased  number  of  leukocytes  in  carcinoma 
as  evidence  of  lymphatic  involvement.  The  increase  is  usually  on  the 
part  of  the  mononuclears,^  particularly  in  sarcomas.    The  specific  gravit}' 

^  Riforma  med.,  1903,  xix,  1037.  2  M^rcotte,  These  de  Paris,  1902. 


h'/fj/jjc/cn.  c/i./k./cr/.R/sr/cs  :',:> 

ot  tlu'  Mooil  IS  s;ii(l  to  1)1-  lisstiud  iii  (.MirmoiiKi  ;iiul  tlu  ;ilk;ilinit\  ic- 
diicid.  A  fcrnunt  with  jiown  to  nt;ii(l  tin-  di^cstioii  ot  ;ill)imiiii  has 
ht'cn  (Itsii  ihid,  hilt  thr  s;inu-  has  hi(  n  ohsiiAcd  in  lailuxia  Iroiii  orhiT 
causes. 

BIOLOGICAL   CHARACTERISTICS 

I' loni  thi'  toiiiiomsi,  ir  will  In-  sctn  rhar  rhcii-  is  jiicar  saiiarioii  m 
rhi-  htha\ior  ot  riiiiiois,  souk-  tciuhiiL:;  to  (l(.srio\'  rhc  siniouiKhiiji  tissue, 
others  only  to  disphice  it.  In  ^ciural,  the  tormer  tend  to  destro\'  the 
life  ot  the  patient,  and  are,  theretore,  called  malignant,  while  the  latter 
do  not,  and  are  called  benign.  These  were  prima ril\  clinical  conci|i- 
tu)ns  with  which  it  was  s<)U<i;ht  to  hannom/e  the  pathological  anatonu'. 
Later,  with  the  development  of  knowledge  of  the  structure  ot  tumors 
the  terms  beni^nanc}'  and  malignancy  were  defined  in  terms  of  patholoj^y, 
and  clinicians  attempted  to  conform  to  them.  Because  of  this,  much 
confusion  has  arisen.  Our  present  conceptions  of  malignanc\'  and 
benignancy  are  based  upon  the  habits  of  growth  of  the  tumor  relative 
to  the  surrounding  tissue  rather  than  their  disposition  to  destro\'  the 
life  of  the  host.  If  a  clinical  definition  of  these  biological  t\pes  of  tumors 
is  desirable,  it  may  be  stated  that  the  malignant  tumors  are  those  which 
invariably  destroy  the  life  of  the  patient  by  virtue  of  their  habits  of 
growth,  wdiile  benign  tumors  are  those  which  do  not  affect  the  individual 
at  all  or  at  most  onl\'  mechanicall}',  or  cause  death  b\'  means  other  than 
their  biological  characters.  Fhese  means  ma^"  be  pressure  within  an 
enclosed  cavit}',  as  in  the  cranium  or  about  an  outlet  duct  (gall-bladder 
or  intestinal  tract),  or  by  some  degenerative  change  within  the  tumor 
(m^'oma  of  the  uterus).  Malignanc}'  in  its  pathological  sense  is  depend- 
ent upon  three  factors,  viz.,  the  disposition  of  tumors  to  recur  when 
removed,  to  form  distant  metastases,  and  to  produce  a  substance  dele- 
terious to  the  general  health.  The  benign  tumors,  on  the  other  hand. 
do  not  possess  these  characteristics.  Too  much  emphasis  has  been 
placed  upon  the  division  into  malignant  and  benign  tumors.  A  tumor 
manifesting  the  biological  characters  of  a  benign  tumor  may  menace 
the  life  of  the  patient  to  a  greater  e.xtent  than  tumors  which  from  their 
character  of  growth  must  be  classed  as  malignant.  Ihus  a  large  myoma 
of  the  uterus,  because  of  its  proneness  to  undergo  secondary  changes, 
or  an  ovarian  cyst  capable  of  rapid  growth,  is  a  greater  menace  to  the 
life  of  the  patient  than  a  basal-celled  epithelioma  of  the  face,  an  endo- 
thelioma of  the  back,  or  a  giant-celled  sarcoma  of  the  tendon  sheath. 

Each  of  these  signs  of  malignanc}'  emphasizes  the  often  repeated 
statement  that  a  tumor  is  an  autonomous  purposeless  growth.  When 
the  classification  of  a  given  tumor  is  attempted  from  its  structure  alone. 


36  THE  GENERAL  BIOLOGY  OF  TUMORS 

confusion  and  uncertainty  often  arise.  The  physiological  properties 
can  be  predicted  but  imperfectly  yet  with  a  certain  degree  of  probability 
by  the  pathological  histology;  but  it  is  the  changes  exhibited  by  the 
cells,  the  relation  they  bear  to  the  surrounding  tissue,  and  the  changes 
within  the  cells  manifested  by  the  degree  of  anaplasia  that  furnish  the 
chief  evidence.  However,  not  infrequently  tumors  showing  exten- 
sive deviation  from  the  normal  as  regards  their  relation  to  surrounding 
tissue  and  the  degree  of  cell  changes  have  little  tendency  to  destro}^ 
life,  while  others  deviating  little  from  the  normal  recur  with  persist- 
ence and  metastasize  early. 


REGRESSIVE   CHANGES 

The  changes  common  to  all  tissue  may  be  undergone  by  the  tissue 
of  tumors.  This  applies  to  both  the  parenchyma  and  the  stroma.  As 
already  stated,  this  is  in  part  dependent  upon  the  state  of  nutrition. 
The  general  law  determining  the  occurrence  of  regressive  changes  in 
tumors  is  the  same  as  that  governing  similar  changes  in  normal  tissue, 
and  is  chiefly  a  problem  in  nutrition.  Some  tumor  cells  possess  a  les- 
sened resistance  to  nutritive  changes,  and  are  most  apt  to  show  the 
influence  of  a  disturbed  nutrition.  The  vessels  are  imperfectly  formed 
and  are  more  prone  to  suflFer  injury.  Vessels  may  become  thrombosed 
by  the  invasion  of  tumor  cells,  or  may  become  occluded  by  twisting  of 
the  base  of  the  tumor,  and  thus  cause  degeneration  or  necrosis  of  the 
region  supplied.  The  result  varies  with  the  conditions.  Complete 
necrosis  may  take  place  or  an  area  of  degeneration  or  liquefaction  and 
cyst  formation  may  result.  If  the  necrosed  area  comes  in  contact  with 
a  bacteria-laden  surface,  infection  follows  and  the  resultant  disturb- 
ances are  added  to  those  inherent  in  the  tumor.  With  less  degrees 
of  nutritive  disturbance  ordinary  degenerative  processes  take  place, 
especially  myxoid,  colloid,  and  hyaline  changes.  These  may  remain 
as  such  or  may  undergo  further  changes  and  form  cj^sts.  Direct  lique- 
faction of  the  degenerated  areas  may  result  in  cyst  formation  and 
hemorrhage  into  the  cyst. 


CHANGES  OF  ONE  TUMOR  TYPE  INTO  ANOTHER 

A  common  expression  in  tumor  literature  is  that  a  certain  tumor 
has  undergone  malignant  degeneration.  Some  authors  have  held  that 
this  expression  is  a  misnomer^  What  really  occurred,  according  to 
them,  was  that  a  malignant  tumor  sprang  up  at  the  site  of  a  preexist- 


ETioLov.y  or  rcMoks  37 

in^  luiii^n  rumor,  or  that  tlu-  supposcdl)  l)ciii;;ii  tuiiiof  was  malignant 
from  rlu-  Iniiiiiniiiti  aiul  oiilv  late  showed  its  niali^naiu  rendencies. 
\\  lull  the  ehanm-  in  tiiinoi  t  \  pc  is  |)tihaps  less  common  than  formerh' 
supposed,  theie  can  he  no  douht  that  tiimois  may  ehanj^e  their  char- 
acter. I  he  common  examples  are  skin  pajiillomas  and  m\()mas  of  the 
uterus,  which,  ordmaiiU  heni<;n,  may  hecome  malignant  In  hoth 
these  types  it  is  often  possible  to  trace  with  a  defi;ree  of  certainty  the 
chanp;es  from  the  cells  of  one  kind  of  tumor  into  those  of  another.  Nor 
should  this  occasion  surprise.  It  is  easily  conceivable  that  cells  which 
havinji;  alread\-  departed  from  the  normal,  as  evidenced  by  their  limit- 
less growth,  may  in  response  to  some  new  stimulus  depart  still  farther 
from  the  normal  and  form  a  definitely  malignant  tumor.  On  the  other 
hand,  there  is  no  doubt  that  clinicians  are  too  free  in  assuming  malig- 
nant degeneration  of  a  previously  benign  tumor,  disregarding  the  fact 
that  manA-  tumors,  primarily  malignant  develop  slowly  for  a  long  time. 
It  is  impossible  to  draw  an  exact  hne  between  these  two  classes. 


ETIOLOGY 

The  causation  of  tumors,  despite  the  effort  of  a  large  army  of  w^orkers, 
has  not  }'et  been  solved;  still,  although  the  actual  causative  factor  has 
not  been  determined,  the  conditions  under  which  tumors  develop  are 
better  understood.  The  study  of  the  etiology  has  been  pursued  in  everv 
possible  direction.  A  wealth  of  statistical  material  of  great  practical 
interest  has  been  collected.  The  search  for  a  specific  organism  has 
failed  to  disclose  a  parasite,  but  has  increased  the  faith  of  most  pathol- 
ogists in  the  theory  of  cell  autonomy.  Animal  experimentation  has 
served  to  strengthen  the  belief  in  the  specificity^  of  the  cell,  and  has 
in  addition  elicited  many  facts  bearing  upon  the  relation  of  the  tumor 
to  the  organism  as  a  whole.  This  in  turn  has  renewed  the  interest 
in  the  stud\'  of  the  life  history  of  spontaneous  tumor  in  man  as  well 
as  in  the  lower  animals.  A  survey  of  the  various  theories  is  of  great 
importance  for  the  proper  comprehension  of  the  views  now  generalh' 
held  by  pathologists.  For  the  purpose  of  the  study  of  their  causation, 
tumors  may  be  placed  under  two  great  groups,  the  congenital  and  the 
acquired. 

The  Congenital  Tumors  fCohnheim's  Theory). — Certain  tumors 
are  unquestionably  congenital.  Nevi,  melanomas,  dermoids,  and 
teratomas  belong  to  this  group.  Some  of  these  remain  stationar\'  or 
grow"  onh'  wnth  the  host.  These,  when  stationary-,  are  more  properly- 
regarded  as  developmental  anomalies.  Some  of  them  take  on  a  con- 
tinued growth  independent  of  the  host,  as  dermoids  or  certain   mixed 


38  THE  GENERAL  BIOLOGY  OF  TUMORS 

tumors,  remaining,  however,  within  their  own  capsule  and  developmg 
in  a  great  measure  as  independent  organisms.  Others,  breaking  through 
their  natural  boundaries,  begin  a  rapid  growth,  invade  surrounding 
tissue,  and  present  other  evidence  of  malignancy.  The  border-line 
between  these  is  not  sharp.  A  few  congenital  tumors  are  malignant, 
but  usually  they  are  benign,  though  they  frequently  possess  a  latent 
malignancy.  A  number  of  earlier  observers  noted  this  association 
of  developmental  anomalies  and  tumor  formation,  but  it  remained  for 
Cohnheim^  to  develop  the  idea  into  a  theory.  The  case  which  brought 
about  the  development  of  this  theory  was  a  renal  teratoma  which  became 
the  starting  point  of  a  sarcoma.  He  therefore  assumed  that  at  some 
period  of  embryonal  life  cell  masses  become  displaced  and,  as  was  un- 
questionably true  in  the  instance  just  cited,  lie  dormant  for  prolonged 
periods.  This  period  of  embryonal  displacement  must  needs  he  between 
the  formations  of  the  blastodermic  layers  and  the  anlages  of  the  organs. 
These  displaced  cells  may  lie  unchanged  indefinitely,  as  seen  in  the 
mixed  tumors,  but  may  at  the  instance  of  some  stimulus  begin  to  pro- 
liferate. This  stimulus  may  be  an  increased  blood  supply,  such  as 
would  be  brought  about  by  injury  or  by  an  inflammatory  process. 
Puberty  and  pregnancy  may  exert  an  influence.  These  misplaced 
nests  are  usually  held  in  check  by  the  surrounding  tissue,  which  may 
be  sufl&cient  in  earl}^  life,  but  in  late  life  the  changing  character  of  the 
tissue  m.2iY  cease  to  furnish  the  necessary  restraining  influence.  The 
rate  of  growth  of  the  displaced  cells  when  they  begin  to  proliferate 
is  dependent  upon  the  stage  of  development  at  which  the  embryo  had 
arrived  when  the  displacement  occurred.  The  earlier  the  period  of 
development  the  more  rapid  is  the  growth. 

The  occurrence  of  carcinomas  at  orifices  where  two  types  of  epithe- 
lium come  together  was  believed  by  Cohnheim  to  be  due  to  the  fact 
that  congenital  displacement  was  apt  to  occur  at  these  points.  We 
now  know  that  the  origin  of  carcinoma  at  points  of  junction  of  two 
types  of  epithelium,  except  at  the  cervix,  is  comparatively  rare.  The 
cardiac  end  of  the  esophagus,  particularly  cited  by  Cohnheim  in  illus- 
trating this  point,  is  the  seat  of  carcinoma  less  often  than  the  pyloric 
region,  where  such  anatomical  relation  of  difi^erent  kinds  of  cells  does 
not  exist.  The  cervix  alone  fulfils  the  requirements  of  his  argument. 
Squamous  and  columnar  epithelium  here  meet  and  it  is  a  frequent 
site  of  carcinoma.  Examined  more  closely,  however,  it  is  clear  that 
even  here  the  beginning  is  in  either  the  one  or  the  other  type  of  epithe- 
lium, and  under  conditions  that  underlie  beginning  carcinoma  elsewhere; 
there  is  no  evidence  that  any  accident  incident  to  development  is  in 

^  Vorlesungen  iiber  allg.  Pathol.,  Hirschwald,  Berlin,  1877,  vol.  i. 


I'/rioLocY  or  ri MORS  39 

an\  \\;i\  ;i  pnilisposiiis;  huToi.  In  t.ixoi  ol  ( 'olinhcinrs  iIuoin  it  may 
be  saul  iIkii  tluii-  can  he  no  (|ut-sti(>n  l>ui  ih.n  niiani  imnois  aic-  con- 
genital, and  ni  nunuious  otiui  cases  (K\  ciopnunral  tictct  rs  hiinisli  tin- 
stairuiti  jionit  loi  the  runiois.  I'.nihi  \()nias  aic  trc(|iicnrl\'  the  site 
tor  rlic  (kxtlopnuiit  ot  saiconia.  II  \  |)c  rn(  pluonias,  n(\i,  and  pig- 
mented moles  aic  cxampks  ot  Miipiili'ct  dcNelopnuiit  ot  cells  which 
furnish  a  ticciucnt  jiomt  ot  tiepartiiic  loi  tumor  tormarion.  Hianchio- 
genic  caicmomas  arc  likewise  txamplcs  of  tumors  startmg  out  tiom 
developnu  nral  tests.  I  he  most  that  can  he  said  tot  this  Inpothesis  is 
that  it  accounts  tor  the  origin  ot  a  limited  hut  detimte  gr(;up  of  tumors. 
It  leaves  unaccounted  for,  however,  the  stimulus  which  excites  to 
development  the  cells  thus  displaced.  The  fact  that  the  known  c(jn- 
genital  tumors  rarely  become  malignant  is  evidence  against  the  Cohn- 
heim  theor\'.  Many  of  the  sarcomas  of  young  persons  cannot  be 
demonstrated  as  arising  from  congenital  tumors,  though  such  an  origin 
IS  otten  assumed;  but  it  is  particulai"l\'  the  carcinomas  that  the  theory 
leaves  unexplained.  It  is  only  in  those  rare  instances  in  which  malig- 
nant epithelial  proliferation  takes  place  in  embryomas  that  such 
relationship  can  be  proved.  It  is  impossible  to  explain  by  the  embryonal 
theory  those  carcinomas  occurring  in  the  scars  of  burns  or  in  chronic 
ulcers.  That  malignant  growths  are  uncommon  in  negroes  and  other 
inferior  races,  and  in  the  lower  animals  in  which  accidents  of  develop- 
ment are  as  common  as  in  the  human  subject,  is  cited  b)'  Lewin'  as 
an  additional  argument  against  the  validity  of  the  hj^pothesis.  The 
greatest  argument  against  the  h}"pothesis,  however,  is  in  the  morpho- 
logical resemblance  of  the  tumor  cell  to  the  adult  cells.  1  he  difference 
is  histologically  but  slightly  apparent,  and  in  man}-  instances  the  tumor 
cells  are  able  to  carr}^  on  the  function  of  the  normal  organ.  On  the 
contrar}^,  they  bear  no  resemblance  to  embryonal  cells,  which  would 
be  the  case  if  they  sprang  from  them.  This  fact  alone  is  sutficient  to 
disprove  the  general  applicability  of  the  hA'pothesis.  While  limited 
in  its  applicability,  the  value  of  Cohnheim's  theor\'  has  been  great, 
in  that  It  was  the  first  plausible  explanation  of  the  development  of 
tumors  which  took  into  account  cellular  pathology.  It  pointed  the 
direction  in  which  subsequent  studies  should  be  pursued  and  gave  a 
stimulus  to  that  histological  study  of  tumors  which  has  done  so  much 
to  discredit  it.  It  paved  the  wa}*  and  still  serves  as  the  basis  for  the 
ever  broadening  theories  of  cell  autonomw  It  is  for  these  reasons  worth\" 
of  a  place  in  classic  tumor  literature. 

Many   attempts   have   been    made   to   remedy    the   defects   of  Cohn- 
heim's theory  and  to  extend  its  application.     Borrmann-  assumed  that 

^  Die  bosartigen  GeschwLilsten,  Kleinkhurdt.  Leipzig,  1909. 
^  Ergeb.  d.  allg.  Path.  u.  path.  Anat.,  1900-1901,  vii,  833. 


40  THE  GENERAL  BIOLOGY  OF  TUMORS 

carcinoma  developing  without  connection  with  epitheHum  must  have 
begun  in  isolated  nests  of  epithelium.  This  addition  to  Cohnheim's 
theory  aims  to  make  it  applicable  to  all  classes  of  tumors  at  all  periods 
of  life.  Wilms, ^  in  the  light  of  his  researches  on  mixed  tumors,  attempted 
to  explain  the  late  spontaneous  manifestation  of  activity  of  mixed 
tumors  upon  the  ground  that  being  independent  of  the  surrounding 
tissue  they  are  not  constrained  by  it.  He  attempted  to  substantiate 
this  hypothesis  by  experimental  evidence,  but  without  definite  results. 
Rather  more  noteworthy  is  the  attempt  of  Ribbert^  to  extend  the 
validity  of  Cohnheim's  theory.  He  assumed  that  the  dislocation  of 
tissue  was  operative  not  only  during  embryonal,  but  also  adult  life. 
By  the  proliferation  of  connective  tissue  about  epithelial  cell  columns 
the  cells  are  separated  from  the  remaining  cells.  When  thus  separated 
they  are  freed  from  the  restraint  such  union  imposes,  and  are  then  capable 
of  further  proliferation.  The  primary  process,  therefore,  was  in  the 
connective  tissue  which  brought  about  a  liberation  of  epithelium.  He 
later  amended  this  by  assuming  that  an  actual  isolation  of  epithelium 
was  not  necessaiy,  but  that  some  change  in  the  connective  tissue  pre- 
ceded the  epithelial  proliferation.  In  this  assumption  he  approaches 
more  nearly  the  theory  of  Thiersch  than  that  of  Cohnheim.  Ribbert's 
theory  takes  into  account  many  conditions  under  which  cancers  develop, 
but  it  leaves  without  explanation  the  actual  cause  of  the  beginning 
of  the  process.  Epithelium  experimentally  isolated  does  not  go  on  to 
proliferation.     Other  factors  must,  therefore,  be  at  work. 

The  sum  total  of  the  efforts  at  the  establishment  of  the  theory  of 
congenital  origin  of  tumors  consists  in  showing  that  certain  tumors 
arise  as  the  result  of  error  in  development.  It  leaves  unexplained 
why  these  displaced  tissues  proliferate  under  certain  conditions.  The 
material  only  is  identified,  the  causative  factors  are  not  indicated. 
For  the  vast  majority  of  tumors  the  source  of  the  malignant  cells  is 
not  explained  in  a  satisfactory  manner.  The  attempts  at  the  extension 
of  Cohnheim's  theory  have  served  to  emphasize  rather  than  to  remove 
its  limitations. 

The  Acquired  Tumors. — The  congenital  theories  offer  no  satisfac- 
tory explanation  for  the  vast  majority  of  tumors,  and  especially  for 
those  of  epithelial  origin.  Since  the  establishment  of  the  cellular  pathol- 
ogy, which  culminated  in  Virchow's^  work,  it  has  been  recognized  that 
all  cells  come  from  preexistent  cells.  If  the  cells  of  the  tumors  do  not 
arise  from  congenital  cells  they  must  come  from  adult  cells.  The  cytol- 
ogy has  been  worked  out  carefully.     The  character  of  the  changes  is 

1  Die  Mischgeschwiilste,  Georgi,  Leipzig,  1900. 

2  Beitr.  z.  Entsteh.  d.  Geschwiilste,  Cohen,  Bonn,  1906-1907. 

3  Die  Cellularpathologie,  Hirschwald,  Berlin,  1871,  4th  ed. 


KTlOUniY  or  r I  MORS  41 

imi'tortant  ami  tlu  sinculation  as  lo  tin-  caust-  is  iiitirisnn^.  I  he 
changes  which  taki-  plact  iii  ci  lis  \shcn  uiulcrgoinji  the  transition  tioni 
normal  to  mahi^nant  ha\i-  hciii  chisseil  iiiulcr  several  heads. 

Metaplasia.  \\\  metaplasia  is  meant  a  change  of  the  cell  t\  pe.  it 
has  luin  luietotoie  Ih1ii\  iil  that  such  changes  could  take  place  ireel\  . 
Rihheit  has  insisted  that  this  supposition  does  violence  to  biological 
laws,  lie  helicNes  that  \anation  in  cell  t\pe  is  held  in  as  close  bounds 
as  is  \aiiation  in  tlu  animal  species.  Most  pathologists  believe  that 
changes  withm  nanow  limits  are  possible,  and  a  tew  men  of  prominence 
are  disposed  to  accept  very  broad  limits.  Changes  have  been  most 
certainly  demonstrated  in  epithelial  cells.  1  he  deviation  is  from  a 
higher  to  a  lower  order.  Columnar  cells  may  become  cuboidal  or  sc|ua- 
mous  and  take  on  the  structure  and  function  of  epidermoid  cells  but 
squamous  epidermoid  cells  never  become  columnar  and  acquire  a  secre- 
tory function.  When  squamous  cells  become  cuboidal  it  is  evidence 
of  reversion  of  developed  squamous  cells  to  an  earlier  less  differentiated 
state  and  not  of  an  approach  to  the  columnar. 

What  has  been  often  regarded  as  evidence  of  change  in  cell  type 
has  been  an  e.xample  of  the  replacement  b\'  a  suitable  type  of  cells  which, 
being  unsuited  for  the  changed  conditions,  have  disappeared.  This 
is  well  shown  in  the  cervix  of  the  uterus.  The  columnar  cells  frequently 
extend  out  much  farther  than  the  usual  line  of  demarcation.  This 
comes  about  not  by  a  metaplasia  of  the  squamous  cells,  but  by  a  destruc- 
tion of  the  squamous  epithelium  and  a  replacement  at  its  expense  by 
the  columnar  cells.  In  other  regions,  as  in  the  urinar;-  bladder,  areas 
are  frequenth'  covered  with  squamous  epithelium.  This  mzy  be  due 
to  a  congenital  dislocation.  In  the  trachea  islands  of  squamous  cells 
are  normally  found,  and  it  is  possible  that  such  islands  may  be  dis- 
covered in  other  regions  where  cells  have  heretofore  been  considered 
to  undergo  metaplasia.  Experimental  metamorphosis  has  been  pro- 
duced by  ligation  of  the  outlet  ducts  of  one  of  the  sahvary  glands.  Here 
the  columnar  cells  of  the  duct  after  a  few  months  give  place  to  squa- 
mous epithelium.  The  change  in  form  here  is,  more  properly  speaking, 
due  to  pressure  rather  than  to  a  change  in  structure.  On  the  other 
hand,  the  occurrence  of  squamous-celled  cancer  in  the  gall-bladder 
can  be  explained  only  on  the  ground  of  metaplasia,  as  even  Ribbert 
admits.  The  same  is  unquestionabl\'  true  for  squamous-celled  metas- 
tasis in  the  lung  from  carcinoma  of  the  stomach.  In  hemorrhoids 
long  prolapsed  the  columnar  epithelium  of  the  rectum  may  be  replaced 
by  squamous  epithelium,  and  it  is  eas}'  to  conceive  the  development 
of  carcinoma  from  it. 

While  it  has  been  definitely  proved  that  epithelial  cells  of  one  t}"pe 
may  change  into  epithelial  cells  of  another  type,  it  is  difficult  to  decide 


42  THE  GENERAL  BIOLOGY  OF  TUMORS 

if  one  kind  of  cell  may  be  changed  into  a  cell  of  another  kind.  For 
instance,  the  question  which  presents  itself  most  often  is  whether  bone 
may  be  developed  at  some  distance  from  any  known  anlage  of  bone. 
In  certain  muscles  true  bone  formation  occurs.  It  may  be  assumed 
either  that  the  connective  tissue  of  the  region  has  the  power  to  undergo 
such  change,  or  that  embryonal  bone  cells  have  been  misplaced  to  this 
region  during  development.  Both  lack  final  proof.  Many  changes 
observed  in  a  tumor  ma}^  be  ascribed  to  degenerative  processes,  e.  g., 
the  formation  of  myxoid  tissue  in  libromas  and  the  development  of 
fat  in  the  same  tumor,  or  to  the  simultaneous  proliferation  of  different 
tissues.  Some  observers  are  disposed  to  accept  much  greater  possi- 
bihties  than  the  opinion  above  indicated,  believing  that  it  is  possible 
not  only  for  tissue  types  to  change,  but  also  for  one  group  to  change 
into  another.  Lubarsch  remarks  that  he  would  not  shrmk  from  admit- 
ting the  possibility  of  epithelium  changing  mto  connective  tissue.  The 
evidence  he  cites  is  the  appearance  of  epithelial  cells  in  some  carcinomas 
so  closely  resembling  connective  tissue  that  a  differentiation  may  be 
impossible.  Changes  of  epithelial  tumors  into  sarcoma  in  experi- 
mental tumor  transplantation  have  been  regarded  as  additional  evidence. 
We  are  ignorant  of  the  influence  operative  in  determining  the  formation 
of  any  kind  of  tissue,  and  we  can  best  ascribe  it  to  hereditary  influences. 
Those  changes  which  do  take  place  Ribbert  believes  happen  because 
the  cells  first  assume  a  lower  order  and  then  re-differentiate  into  a  new 
higher  type. 

It  is  probable  that  metaplasia  in  tumors  is  confined  within  rather 
narrow  limits.  The  problem  finds  its  importance  not  onl}-^  in  the  etiology 
of  tumors  primarily,  but  also  in  the  metamiorphosis  of  tumors  of 
changing  type.  Some  pathologists  contend  that  instead  of  a  change  in 
the  type  of  tumor,  a  so-called  malignant  degeneration,  the  tumor  was 
malignant  from  the  beginning,  and  that  when  a  benign  tumor  takes 
on  malignant  growth  it  is  a  newgrowth  superimposed  upon  the  primary 
benign  growth.  It  would  seem  that  this  assumption  ignores  much 
definite  observation  for  the  purpose  of  maintaining  the  integrity  of 
a  theorv.  In  myomas  of  the  uterus  the  transition  from  the  myoma 
cells  to  malignant  cells  often  may  be  traced  definitely.  The  transi- 
tion appears  to  be  direct  without  the  intermediate  reversion  to  a  lower 
type.  A  local  agent  of  unknown  character  seems  to  be  able  to  stimu- 
late an  adult  resting  cell  to  a  development  that  is  atypical  and  un- 
limited. 

Regression  (Riickschlag). — By  regression,  Ribbert  means  a  process 
of  cell  change  whereby  cells  relapse  from  a  more  differentiated  plane 
to  a  lower,  less  differentiated  plane.  It  differs  from  metaplasia,  with 
which   it  is  frequently  confused,   in   that  it  assumes  a  change  from   a 


/■rr/o/.ocr  oi  timors  43 

hi^lur  to  a  l()\Mr  onlci  ot  chrtt-rc-iuiarioii,  wink-  nR-ra|')lasia  assunic-s 
a  cliaii^c  from  oiu-  t\  jic  of  cell  into  ancjther  t}pc  of  an  ecjiial  decree 
of  tlirtcrcntiation.  Regression  finds  its  best  example  in  the  changes 
which  connective-tissue  cells  undergo  in  inHammaror\  and  healing 
processes.  I  he  ceils  react  h\  heconung  larger  and  rouiuli  r,  ajipai- 
ently  resuming  the  partially  de\elo|ied  stage.  In  like  manner,  eiuhjthe- 
lial  cells  may  become  cuboidal  and  resemble  in  a  general  way  epithelial 
cells,  without,  however,  taking  on  an\-  ot  the  biological  characters  of 
epithelium.  Epithelium  likewise  undergoes  similar  changes.  Epidermal 
epithelium  may  lose  its  prickles  and  the  c\toplasm  may  alter  its  struc- 
ture. 

In  the  more  highly  developed  cells  changes  are  less  obvious  if  the\ 
occur  at  all.  Muscle  cells  undergo  certain  changes  in  form  and  struc- 
ture, but  in  specialized  cells  generally  regression  is  confined  to  the 
cytoplasm.  This  slight  disposition  to  change  may  account  for  the 
rarity  of  primar}'  tumors  in  these  tissues. 

The  changes  in  cells  are  never  abrupt,  and  it  is  necessar\-  in  man\- 
cases  to  trace  them  through  the  various  stages  to  ascertain  their  origin. 
Eor  instance,  in  epitheliomas  the  cells  first  lose  their  prickles  and  become 
rounder,  keratohyalin  is  no  longer  formed,  and  as  the  deviation  be- 
comes greater  the  cells  become  smaller,  due  to  a  lessened  amount  of 
protoplasm. 

Anaplasia. — By  anaplasia  is  meant  the  process,  both  morphological 
and  physiological,  whereb}'  cells  change  their  character  and  become 
converted  into  a  type  not  normal  to  any  period  of  development,  form- 
ing a  cell  with  characters  entireh'  distinct  from  normal  cells.  Morpho- 
logically the  change  consists  in  a  deviation  from  the  normal  cell  division. 
Hypochromatic  and  hyperchromatic  cells  are  observed.  The  chief 
difference  lies  in  the  fact  that  the  number  of  chromosomes  in  the  poles 
varies  so  that  daughter  cells  of  varying  size  are  produced  and  the 
resemblance  to  the  mother  cell  is  thereby  lost.  Physiologicallv  this 
deviation  finds  expression  in  the  increased  capacity  of  proliferation 
of  the  cells  of  a  lower  order  which  the  atypical  mitosis  has  produced. 
The  greater  the  morphological  deviation  the  correspondingly  greater 
is  the  physiological.  Hansemann,'  who  originated  the  term  "anaplasia," 
regarded  these  observations  of  etiological  importance.  Such  changes 
are  often  observed,  but  they  are  not  confined  to  malignant  processes, 
being  observed  in  regenerative  processes  and  often  absent  in  beginning 
carcinomas.  Most  pathologists  regard  atypical  mitosis  as  an  expres- 
sion of  bewildered  growth  and  not  a  cause  of  it. 

Changes  within  the  cells  above  noted  are  structural,  but  in  tumors 

'  Die  niikroskopische  Diagnose  der  bosartigen  Geschwiilste,  Hirschwald,  Berlin,  1897. 


44  THE  GENERAL  BIOLOGY  OF   TUMORS 

the  chief  factors  are  physiological.  The  power  of  proliferation  beyond 
normal  limits  is  the  essential,  and  this  does  not  run  parallel  with  the 
morphological  changes.  Both  are  alwaj^s  present,  but  in  varying  degrees. 
It  is  important  to  remember  that  structure  alone  is  not  sufficient  to 
determine  the  character  and  potentiality  of  the  tumor. 

Changes  in  the  Tissue  Balance. — Attempts  at  explaining  the  actual 
causation  of  the  cell  proliferation  have  been  made.  The  most  note- 
worthy IS  the  theory  of  Thiersch,^  that  the  primar\'  change  is  in  the 
connective  tissue,  whereby  the  lessened  resistance  of  the  senile  connec- 
tive tissue  permits  the  epithelium  to  proliferate.  This  is  based  upon 
the  assumption  that  there  is  an  antagonism  between  the  epithelium 
and  connective  tissue.  The  epithelium,  which  predominates  in  the 
embryo,  is  held  m  check  in  the  adult  by  the  connective  tissue.  When 
the  connective  tissue,  notably  the  basement  membrane,  undergoes 
degeneration,  the  epithelium,  released  from  this  restraint,  resumes  the 
proliferative  capacity  of  the  embryonal  cells.  This  explains  the  fre- 
quent occurrence  of  carcinoma  in  advanced  life,  but  it  does  not  take 
account  of  the  local  occurrence  of  carcinoma  nor  its  occurrence  in 
earl}^  life. 

Acidobasic  Tissue  Reaction  Theory.- — I  have  attempted  to  develop  the 
theory  of  Thiersch  by  a  tinctorial  study  of  the  tissues  in  order  to  deter- 
mine the  relation  of  connective-tissue  changes  as  revealed  b}^  tinctorial 
chemistry. 

In  the  senile  subepithelial  connective-tissue  changes  of  slight  and 
inconstant  degree  may  be  demonstrated,  but  these  changes  are  not 
local  nor  are  they  present  at  the  places  and  time  of  maximum  frequency 
of  tumor  formation.  There  is  much  of  interest,  however,  that  seems 
to  explain  the  conditions  under  which  tumors  develop. 

The  most  common  accompaniment  of  carcinoma,  chronic  irritation, 
is  attended  by  changes  in  the  connective  tissue.  Round-celled  infiltra- 
tion, when  existent  for  any  length  of  time,  is  attended  by  a  decrease 
in  the  acidophilic  reaction  of  the  connective  tissue.  In  these  regions 
it  is  common  to  observe  a  degree  of  epithelial  proliferation.  These 
changes  are  seen  about  all  ulcers. 

Parallel  with  the  changes  produced  by  irritation  are  those  produced 
by  the  injection  of  certain  d3^es  (Scharlach  R,  Sudan  III).  An  active 
epithelial  proliferation  takes  place  which  Fischer^  ascribed  to  an  "attrac- 
tion" for  the  epithelial  cells.  He  called  the  dye,  therefore,  an  "attraxin." 
The  changes  are  primarily  in  the  connective  tissue  and  resemble  the 

^  Der  Epithelkrebs,  Leipzig,  1865. 

■^  For  a  more  complete  presentation   see  Trans.  Western   Surg.  Assoc,    1907;  Jour. 
Amer.  Med.  Assoc,  1908,  1,  425,  and  1910,  Iv,  2290. 
^  Miinch.  med.  Wochenschr.,  1906,  liii,  2041. 


ETiOLoc.y  or  riwfORS  45 

ch;in<;fs  piodiucil  1>\  iliioim-  iiit];imm;i  t  ion.  \\  lun  Sudan  III  or 
Scharlach  R  is  injccrctl  iiiiiiudiarcl)  lulow  tin-  cpit luliuiii,  the  coniu-c- 
tivf  rissiu-  Hist  losi-s  its  reaction  to  acid  dyes,  lollowiii^  this,  tin-  cpi- 
tlulnini  luiiins  to  pioliferate.  The  epitht-lial  prolittratioii  is  coiihnt-d 
to  the-  :\WA  in  which  thr  comucti\c  tissue  has  undergone  its  modified 
reaction  to  acid  d\es.  The  ejiithehiini  retains  its  normal  characters, 
hut  the  mitotic  huures  may  he  ohserved  and  pearl  formatmn  is  common. 
Thi-  (.pitht,  hum  ch)es  not  invade  regions  where  prehmmary  changes  in 
the  connective  tissue  have  not  occurred. 

In  .v-ra\-  carcinomas  all  writers'  who  have  studied  the  lesion  are  agreed 
that  the  piimar\  changes  are  in  the  connective  tissue  and  that  epi- 
thelium hegins  to  proliferate  only  after  such  changes  have  taken  place. 
These  changes  in  the  connective  tissue  seem  to  be  identical  with  those 
produced  by  Sudan  III.  Unlike  the  proliferations  in  the  Sudan  experi- 
ments, however,  the  epithelium  after  a  time  invades  regions  where 
the  tissue  is  still  normal  and  metastases  may  be  formed.  1  he  influence 
of  the  .v-ra\s  upon  the  tissue  is  much  more  widely  diffused  than  in  the 
Sudan  injection,  and  much  longer  periods  are  passed  before  the  growth 
of  the  epithelium  in  the  v-ray  tumor  begins. 

In  beginning  epithelioma  of  the  same  class  of  tissue  there  is  a  change 
in  connective  tissue  closely  resembling  the  changes  in  both  the  Sudan 
experiment  and  in  the  x-r2Ly  carcinoma.  The  connective  tissue  is  less 
cellular  and  it  loses  in  part  its  affinity  for  acid  dyes.  Like  the  latter 
and  unlike  the  former,  the  cells  invade  regions  beyond  which  the  con- 
nective-tissue changes  occur.  In  both  the  spontaneous  and  .v-ra}- 
proliferations  there  is  a  change  in  cell  t^pe.  The  fact  that  the  changes 
in  the  Sudan  experiments  and  in  the  .v-ra}-  cancer  are  primarily  in  the 
connective  tissue  makes  it  seem  probable  that  the  changes  in  the  sponta- 
neous proliferation  are  likewise  in  the  connective  tissue.  Chronic  irrita- 
tion is  attended  b}-  round-cell  infiltration.  In  an\-  acute  inflammatory 
process  the  connective  tissue  loses  temporaril}-  a  part  ot  its  acidophilic 
property,  reverting  to  a  state  approaching  tinctoriall}-  that  of  fibrin. 
When  the  inflammation  subsides  the  normal  affinity  for  acid  d\es  re- 
turns. In  chronic  irritation  in  some  instances  the  reaction  to  certain 
d\'es  is  lessened  and  is  permanent.  In  ascribing  the  pnmary  change 
to  connective  tissue  the  theor\'  of  Ribbert  is  suggested. 

In  none  of  these  instances,  however,  is  epithelium  "liberated"  from 
the  adjacent  epithelium.  On  the  contrary,  the  continuous  growth 
ma}-  easily  be  demonstrated.  The  onl}-  tangible  explanation  is  that 
the  lessened  acidophilic  propert\-  of  the  connective  tissue  permits  the 
invasion  of  the  basophilic  epithelium.      In  certain  regions  the  changes 

1  S.  B.  Wolbach,  Jour.  Med.  Research,  1909,  xxi,  415. 


46  THE  GENERAL  BIOLOGY  OF  TUMORS 

in  the  epithelium  seems  to  be  primary  inasmuch  as  changes  in  cell 
type  and  active  proliferation  may  occur  and  yet  the  surrounding  tissue 
be  not  invaded.  This  is  shown  in  polypoid  proliferation  of  the  uterine 
mucosa.  The  cells  change  in  type,  become  strongly  chromophilic, 
but  the  surrounding  uterine  muscle  is  not  invaded.  The  balance  of 
the  tissue  is  maintained  so  long  as  there  is  not  a  preponderance  of  basic 
over  the  acidophilic  power,  and  we  may  say,  therefore,  that  invasion 
occurs  whenever  the  basic  power  is  excessive  or  the  acidophihc  power 
is  reduced.  The  very  strongly  acidophilic  basement  membrane  may 
be  placed  about  epithelial  (and  endothelial)  cells  as  a  barrier  to  inva- 
sion. For  the  formation  of  metastases  it  may  be  assumed  that  it  is 
necessary  that  the  basic  power  of  the  tumor  cells  is  excessive  or  that 
they  reach  a  region  where  the  acidophilic  power  is  normally  less  than 
in  the  basement  membrane  of  the  region  from  which  the  epithelium 
was  derived.  Carcinoma  metastasis  has  a  predilection  for  regions 
where  the  acidophilic  power  is  normally  less  than  that  of  ordinary 
connective  tissue.  It  is  interesting  in  this  connection  to  note  that  the 
basement  membrane  is  more  strongly  acidophihc  than  ordinary  con- 
nective tissue. 

Parasitic  Theories. — During  the  period  when  the  blasteme  theory 
was  accepted  generally  as  accounting  for  the  prime  etiological  factor 
in  carcinoma  the  contagiousness  of  the  disease  was  maintained.  When 
the  ulcerative  stage  was  reached,  gases  were  supposed  to  escape  which 
carried  the  infective  elements.  Cases  were  reported  to  substantiate 
this  view.  When  the  cellular  theory  was  established,  cases  were  reported 
in  which  infection  by  direct  contact  was  believed  to  have  taken  place. 
Cases  in  which  carcinomas  developed  on  opposing  surfaces,  such  as  the 
lips  and  vulva,  were  reported  and  regarded  as  evidence  of  infectious- 
ness. In  the  reported  cases  in  which  the  diagnosis  was  certain  the 
possibility  of  multiple  primary  origin  cannot  be  excluded.  Instances  of 
epitheliomas  on  opposing  surfaces  of  the  vulva  are  open  to  the  same 
objection.  I  doubt  if  there  is  an  authentic  case  on  record.  In  most 
of  those  recorded  the  diagnosis  was  clinical.  A  case  of  contact  infec- 
tion reported  by  Hartman  and  Lecene  met  the  requirement  that  the 
inoculated  tumors  shall  be  of  the  same  structure  as  the  primary  one, 
but  the  location  was  such  that  other  doubts  enter.  The  case  was  one 
in  which  a  glandular  carcinoma  of  the  cervix  produced  a  glandular 
ulcer  of  the  vagina.  In  this  situation  extension  by  retrograde  metastasis 
through  the  vaginal  veins  seems  more  probable,  smce  the  new  tumor 
was  distinctly  stated  to  be  an  ulcerous  process.  I  saw  recently  a  case 
in  which  the  entire  vaginal  plexus  of  veins  was  infiltrated  from  a  gland- 
ular carcinoma  of  the  cervix.     The  perivascular  tissue  in  many  places 


ETioiJH.Y  or  rrMoRs  I7 

\v;is   iiihlti  ;i  ticl,  aiul    iiisr  ihskIc    tin     \iil\;i    one   ot    tlusi-    IkkI    iilrci  ;ir<(l. 
Such  extt'iisioii  is  nor  iiiuisual  in  s\  ik\  tioiiias. 

rhosi-  cases  calltd  iniicfr  a  dfiix  hy  the  French,  in  which  hiishand 
aiul  wife  htconu-  sinuiltaneoiisly  or  successivtl\  attiictcd,  \scre  citccl 
as  evidence.  Ir  is  {luesrionalde  whither  siiniiliaiuous  occurrence  ot 
carcinoma  ot  the  peins  and  cervix  is  more  than  a  coincidence.  I  hus, 
I)emaiiiua\  reported  134  cases  of  carcinoma  of  the  penis,  and  in  only 
one  was  tliere  a  possibility-  of  contact  infection,  which  seems  rather 
remarkable,  considering  the  frequency  of  carcinoma  of  the  cervix. 
Nearly  all  the  cases  cited  in  substantiation  of  the  possibility  of  contact 
infection  rest  upon  insufficient  evidence.  1  he  nature  of  the  disease 
in  man\'  of  the  cases  reported  is  not  clear,  and  m  tliose  in  which  the 
diagnosis  may  be  accepted  as  correct  the  instances  are  so  rare,  as  com- 
pared with  the  enormous  frequency  of  carcinoma,  that  they  hardly 
impress  one  as  being  more  than  interesting  coincidences. 

1  he  endemic  occurrence  of  carcinoma  has  been  another  factor  in 
the  argument  in  favor  of  its  infectiousness.  It  has  been  noted  that 
in  certain  communities  or  even  houses  carcinoma  occurred  with  unusual 
frequenc}^.  Some  writers  have  sought  to  connect  this  with  the  nature 
of  the  soil  or  drainage.  Thus,  Behia'  collected  many  statistics  tending 
to  show  that  in  some  instances  carcinoma  occurs  with  greater  frequency 
in  regions  where  the  soil  is  badi)'  drained.  The  evidence  in  the  cases 
reported  is  insufficient  to  permit  of  judgment.  The  number  of  persons 
alone  is  mentioned  without  reference  to  age  and  the  presence  of  other 
factors  with  which  carcinoma  is  recognized  as  being  more  or  less  asso- 
ciated. As  Williams  well  remarks,  these  epidemics  have  occurred  in 
remote  rural  communities,  and  not  in  crowded  unsanitary  tenements 
which  ordinarih'  invite  the  transmission  of  communicable  diseases. 
More  recently  the  occurrence  of  epidemics  of  tumors  in  animals  in 
certain  cages  have  been  reported.  Gay  lord'  reports  an  instance  in 
which  from  a  single  cage  60  tumor  mice  were  removed  within  three 
years.  The  location  of  the  cage  was  repeatedly  changed  and  the  stock 
of  mice  once.  It  would  seem,  therefore,  that  the  cage  itself  was  the 
factor  at  fault.  This  places  these  observations  in  the  class  of  epidemic 
occurrence  in  moist  communities.  More  suggestive  still  is  the  occur- 
rence of  peculiar  tumors  in  fishes  in  certain  hatcheries.  Thus,  Pick 
reports  an  instance  in  which  7  per  cent,  in  a  certain  hatchery  were 
affected.  Foreign  fish  procured  to  replenish  the  stock  w'ere  likewise 
affected.  Pick,'^  therefore,  ascribes  the  effect  to  the  water.  The  thyroid 
gland  alone  was  affected.     He  concludes  that  first  a  simple  goitre  w^as 

'  Deutscli.  nied.  \\  ochenschr.,  1901,  .x.wii,  427. 
-Jour.  Amer.  Med.  Assoc,  1907,  xlviii,  15. 
^  Berl.  klin.  Wochenschr.,  1905,  xlii,  1435. 


48  THE  GENERAL  BIOLOGY  OF  TUMORS 

produced  which  later  become  carcinomatous.  The  instances  above 
quoted  are  sufficient  to  show  that  these  observations  are  more  than 
coincidences  and  that  some  truth  ma)'  he  in  the  mass  of  the  reported 
instances. 

When  the  bacterial  origin  of  manj^  diseases  became  definitely  estab- 
lished it  was  no  wonder  that  investigators  turned  to  bacteriology  for 
the  solution  of  the  carcinoma  riddle.  It  has  been  the  absolute  con- 
fidence in  the  correctness  of  the  assumption  which  explains  the  laxity 
with  which  experiments  were  carried  out  and  the  disregard  of  the  ordi- 
nary rules  of  logic  with  which  conclusions  were  formed.  Much  of  the 
evidence  adduced  was  the  result  not  of  impartial  scientific  examina- 
tion into  the  possible  or  even  probable  parasitic  nature  of  cancer,  but 
of  violent  efforts  to  prove  a  prejudged  conclusion.  Much  of  the  argu- 
ment against  the  parasitic  origin  of  cancer  has  been  made,  a  priori, 
an  equally  unsound  procedure.  Many  of  our  proved  scientific  facts 
have  previously  been  proved  impossible  upon  just  such  carpet  philos- 
ophy. While  I  readily  admit  that  the  bulk  of  the  literature  on  the 
subject  should  be  relegated  to  the  museum  of  scientific  folly,  ytt  there 
is  much  work  by  careful  men  that  should  be  known  to  workers  in  this 
field,  and  should  be  kept  in  mind  now  that  the  pendulum  is  swinging 
violently  in  another  direction.  It  is  worth  while,  therefore,  to  present 
in  brief  outline  the  ground  covered  by  these  investigators. 

Three  classes  of  organisms  have  been  advanced  as  the  cause  of  tumor 
formation;  the  bacteria,  the  protozoa,  and  the  blastomycetes.  They 
may  be  considered  in  this  order,  for  it  represents  in  a  rough  way  the 
historical  sequence. 

The  Bacteria. — Even  before  Koch's  epoch-making  discoveries  bacteria 
were  described  in  tumors,  but  it  was  not  until  later  that  they  were  con- 
fidently announced  as  the  cause  of  the  disease.  None  of  them  could 
meet  the  requirements  of  even  one  of  Koch's  laws.  It  was  Scheurlen's^ 
paper  that  received  the  most  attention.  He  produced  a  culture  which 
when  injected  into  the  breast  of  bitches  produced  a  tumor  in  a  month, 
which  he  declared  to  be  of  an  epithelial  nature.  It  was  proved  by 
Baumgarten-  and  others  that  the  organism  was  a  potato  bacillus. 
Moreover,  Shattock  and  Balance^  showed  that  non-ulcerated  tumors 
were  sterile  and  could  be  kept  so  for  a  long  period.  Doyen's^  announce- 
ment of  Micrococcus  neoformans  is  still  fresh  in  our  minds.  He  claimed 
that  his  microbe,  a  diplococcus,  was  always  present  in  malignant  tumors, 
could    be    demonstrated    in    sections,  and  cultivated    in    special    media; 

^  Deutsch.  med.  Wochenschr.,  1887,  xiu,  1033. 

2  Centralbl.  f.  BakterioL,  1888,  iii,  397. 

^  Trans.  Path.  Soc,  London,  1887,  p.  412,  and  1888,  p.  419. 

^  Etiologie  et  Traitement  du  Cancer,  Maloine,  Paris,  1904. 


ETIOI.OC.Y  or  TIMORS  49 

;iiul  that  tumois  coiiKl  l>r  pi  otliu  id  iii  animals  l)\  inoiiilat  ion  uirh 
piiii-  culriiiis.  Monoxn,  In  rlu-  pii|iarari()ii  ot  a  sixiial  roxin  he 
ciainu-cl  to  haw  iiirtii  42  of  242  paticius  attictccl  with  carcinonia. 
His  icsiarclus  win-  consuKiiil  ot  siirticuiit  mi|)ortaiUH-  to  wairaiu 
rlu-  appoiiuiiKiu  ot  a  spctial  coniniittc-e  in  tiie  Scjcicte  de  Chirurf^ie. 
This  conmiirrft''  cxaniiiuil  the-  patients  treated  by  Doyen  over  a  period 
ot  ti\e  months,  ami  tailed  to  tind  a  single-  mstaiue  ot  cure  or  e\en  a 
single  case  ot  amehoiation  ot  the-  s\ miHoms.  I  hese  may  serve  as 
e'xamples  of  the  exideiice  so  far  produced  in  the  attempt  to  establish 
the  direct  relation  of  bacteria  to  the  etiology  of  tumors.  I  p  to  the 
present  time  it  ma\'  safely  be  said  that  bacteria  tound  in  tumors  are 
accidental  infections,  and  while  they  are  present  in  all  ulcerative  tumors, 
no  proof  has  been  adduced  to  show  any  direct  etiological  relationship. 
The  Protozoa. — While  some  contentions  for  the  protozoic  origin  of 
carcinoma  antedate  the  microbic  theories,  they  were  held  in  check 
by  the  statement  of  Virchow-  that  tumors  were  endogenous  cell  forma- 
tions, and  the  real  prominence  of  this  theory  began  onl}'  after  bacterial 
theories  were  proved  untenable.  Each  investigator  has  advanced  his 
own  organism,  which  he  has  proved  to  his  own  satisfaction  as  a  specific 
for  carcinoma.  Man\'  of  these  have  been  dignified  with  special  sonorous 
cognomens,  which  may,  however,  be  left  to  he  in  the  special  literature. 
It  is  pureh'  a  matter  of  present  preference  which  of  the  investigations 
one  shall  select  for  presentation  as  example.  Those  which  have  gained 
particular  prominence  have  been  due  to  the  persistence  or  prominence 
of  the  authors  rather  than  the  character  of  the  organisms  present  or 
any  great  variation  from  those  presented  by  other  investigators.  The 
works  of  Schaudin,^  Sjobring,^  Schiiller,'^  GaAlord,"  and  Feinberg," 
together  with  the  elaborate  work  of  Pianese,'  will  give  the  student  the 
best  notion  of  the  field  covered  by  these  investigations.  Nearly  all  of 
these  works  can  be  obtained  in  monograph  form.  That  of  Feinberg,^ 
ma\'  be  regarded  as  the  final  effort  to  establish  an  etiological  relation- 
ship between  this  type  of  parasite  and  carcinoma.  He  describes  the 
histor}'  of  sporozoa,  and  compares  them  with  normal  cells.  The  inclu- 
sions found  in  certain  tumors  are  then  compared  with  sporozoa  and 
.are   declared   identical.      The   findings   are  familiar,   and    the  argument 

'  Compt.  rend.  Soc.  de  cliir.,  July  15,  1905. 
-  Virchow's  Arch.  f.  path.  Anat.,  1892,  cxxvii,  188. 
'  Sitz  d.  Berl.  Acad.  d.  \\  issensch.,  1896,  xxxix,  951. 
••  Centralbi.  Bakteriol.,  1900,  xxvii,  129. 
•''Die  Parasiten  in  Krebs  und  Sarcom.,  Fischer,  Jena.  1901. 
"  Amer.  Jour.  Med.  Sci.,  1901,  cxxi,  503. 

^  Die  Erreger  und  der  Bau  der  Geschwiilste,  Friedlandcr.  licrlin.  1907. 
^  Beitr.  z.  path.  Anat.  u.  z.  allg.  Path.,  Fischer,  Jena,  Suppl.,  1906. 
^  Loc.  cit. 
4 


50  THE  GENERAL  BIOLOGY  OF  TUMORS 

in  favor  of  their  parasitic  nature  is  purely  academic.  The  relation 
of  the  "parasites"  and  the  tumor,  as  a  whole,  is  not  discussed.  The 
facts  that  have  made  a  parasitic  origin  of  tumors  doubtful  are  not 
considered. 

It  is  extremely  difficult  to  express  in  brief  space  a  comprehensive 
resume  of  the  researches  presented  m  this  voluminous  literature.  The 
evidence  is  largel}^  histological,  and  is  based  mainly  on  tinctorial  chem- 
istry. Some  of  the  investigations  were  made,  it  is  true,  on  fresh  un- 
stained material,  where  motile  organisms  resembling  ameba  have  been 
described,  but  it  is  impossible  to  gain  from  the  descriptions  a  clear 
notion  of  the  author's  findings.  Generally  stained  specimens  were 
studied  which  showed  curious  protozooid  structures  within  or  between 
the  cells.  These  have  been  for  the  most,  part  highly  refractile,  strongly 
acidophilic  bodies  occurring  within  the  cells  of  carcinomas. 

At  the  present  time  these  bodies  are  not  proved  to  be  parasites; 
even  among  their  advocates  no  harmony  exists  as  to  their  classification 
or  source.  It  is  particularly  significant  that  protozoologists  not  inter- 
ested particularly  in  carcinoma  theories  do  not  admit  the  protozoon 
nature  of  the  bodies  in  question.^  The  majority  of  pathologists  regard 
them  as  cell  products  or  evidence  of  cell  degeneration.  The  latter 
assumption  has  much  to  favor  it,  since  they  occur,  at  least  chiefly,  in 
the  older  degenerating  portion  of  the  tumors.  The  lack  of  unanimity 
has  already  been  noted,  and  the  occurrence  of  the  same  bodies  in  con- 
ditions other  than  carcinoma  are  strong  arguments  against  the  etiological 
relationship.  The  fact  that  no  experimental  tumor  has  been  produced, 
and  that  diseases  demonstrably  of  protozoon  origin  do  not  resemble 
carcinoma  either  clinically  or  pathologically,  have  caused  the  question 
to  lose  the  interest  of  clinicians.  The  conclusion  of  Williams,  that 
"the  more  carefully  the  subject  is  considered  the  clearer  it  appears 
that  the  'protozoon  of  cancer'  has  failed  to  make  good  its  identity," 
expresses   the  view  of  most  of  those  who   have   studied   the   problem. 

The  Blastomycetes. — As  a  direct  corollar}^  of  the  foregoing  are  the 
so-called  Russel  bodies  first  described  by  Russel.'  It  was  studies  of 
Sanfehce'*  however,  that  brought  the  structures  into  prominence.  The 
organisms  this  investigator  employed  were  obtained  from  extraneous 
sources,  though  similar  organisms  have  been  obtained  from  tumors 
of  man.  He  claims  to  have  produced  carcinoma  by  them.  The  mass 
of  evidence  indicates  that  the  tumors  produced  by  these  organisms  are 
granulomatous  in  character.'*     The  problem  is  somewhat  confused   by 

1  Doflein,  Die  Protozoen  als  Parasiten  und  Krankheitserreger,  Fischer,  Jena,  1909. 

2  Brit.  Med.  Jour.,  1892,  ii,  1356. 

^  Centralbl.  f.  BakterioL,  xvii,  113,  625;  xviii,  521;  xxi,  254;  xxvii,  155,  156. 
*  Peterson  and  Exner,  Beitr.  z.  klin.  Chir.,  1899,  xxv,  769. 


KTioijH.y  oi   n  MORS  :.] 

the  fact  rhar  ^t-mmu-  Mastoniycotic  disease-  does  occur  in  the  luiinaii 
subjecr.  I  In  usriiihlaiue  to  carcinoiiia,  however,  is  sh^ht  and  explains 
the  contusion  \shuh  has  arisin  in  inocuhition  experiments,  and  serves 
rather  to  coiniiui  thi-  ohseivii  ol  the  non-spteiHcit\  ot  the  or^anisni. 
Spiit)chetes  were  cliseiducl  in  tumors  by  CJaylord'  and  Calkins.-  I  lust- 
were  umtormh  lound  m  Imast  tumors  of  a  series  of  mice  examined  and 
from  tiansplaiHid  tuniois.  I  he  oi<;amsms  wtie  ohser\ed  in  the  borders 
ot  j^rowing  tumors,  thus  tultillmg  some  ot  the  retjuirements  lacking  in 
other  organisms  advanced  as  the  causative  factors  in  carcinoma.  I  yz/er,^ 
however,  described  tumors  of  mice  free  from  them,  and.  what  is  more 
conclusixf,  he  h)inul  spirochetes  in  the  nuchastinuni  in  mice-  m  which 
inoculations  were  unsuccessful.  1  he  spirochete  theory,  theietore,  seems 
to  share  the  same  fate  as  other  parasitic  explanations. 

Such  a  cursory  review  of  some  of  the  more  important  theories  of 
the  causation  of  tumors  and  of  the  conditions  under  w  Inch  the\'  develop 
leaves  the  problem  in  an  unsatisfactory  state.  The  most  striking  fact 
noted  in  the  literature  is  the  collapse  of  the  parasitic  theories  which  were 
once  regarded  as  so  full  of  promise.  Pathologists  have  almost  with- 
out notable  exception  discarded  all  extraneous  factors  as  the  cause 
of  tumors.  Microorganisms  have  been  rejected  with  decision,  often 
with  impatience.  The  cause  of  this  is  that  most  investigators  who 
have  gone  over  the  whole  ground  ha\e  come  to  the  conclusion  that 
the  carcinoma  parasite  is  the  carcinoma  cell  itself.  The  conviction 
that  the  cell  itself  contains  the  secret  of  the  endless  development  w  hich 
characterizes  these  tumors  has  become  nearl\-  universal.  I  his  power 
of  the  cell  to  limitless  growth  has  been  repeatedly  referred  to  as 
autonomy'.  Ewing^  has  summarized  the  more  important  problems  in  a 
masterl\'  manner.  He  correctly  remarks  that  an  appreciation  of  the 
full  meaning  of  the  theory  of  cell  autonomy  is  acquired  only  after 
prolonged  stud\'  of  the  factors  which  go  to  make  it  up.  It  is  the  com- 
posite of  many  theories  advanced  by  many  of  the  foremost  pathologists. 

The  tumor  cell  is  one  which  is  able  to  proliferate  in  an  environment 
in  which  a  normal  cell  does  not  multipl}'.  What  is  known  about  the 
conditions  which  bring  about  this  increased  power  of  proliferation  has 
already  been  discussed. 

Cohnheim's  theor\-  furnishes  a  limited  but  a  positive  basis  tor  our 
belief.  Certain  tumors  unquestionably  arise  in  misplaced  embryonal 
cells.  No  satisfactory  reasons  can  be  given  to  account  for  the  develop- 
ment of  the  cell  in  later  life,  but  it  is  safe  to  say  that  parasitic  theories 
failed   utterh'  to  offer  an  explanation  why   a   parasite  should  select  an 

^  Jour.  Infect.  Dis.,  1907,  iv,  155.  -Ibid.,  171. 

^  Soc.  of  Exper.  Biol.,  New  "^'ork,  1907,  iv,  85. 
^  Cancer  Problems,  Arch.  Int.  Med.,  1908,  i,  175. 


52  THE  GENERAL  BIOLOGY  OF  TUMORS 

isolated  group  of  cells  for  the  exercise  of  its  activity;  but  what  is  more 
convincing,  the  new  tumor  cells  are  observed  to  be  identical  with  the 
embryonal  cells.  In  other  situations  the  facts  are  equally  striking. 
The  tumor  cells  may  be  but  little  altered  from  the  mother  cell.  This 
is  true  not  only  of  the  cells  which  lie  adjoining  to  those  from  which  they 
develop,  but  also  the  cells  of  metastatic  nodules  may  imitate  the  mother 
cells  faithfully.  Adenomas  of  the  digestive  tract  may  form  metastases 
within  the  liver  which  retain  a  distinct  gland  structure,  and  lymph 
gland  metastases  from  glandular  breast  tumors  may  show  a  like  struc- 
ture. Epithelial  tumors  often  retain  their  characteristics  in  metas- 
tases sufficiently  to  permit  the  recognition  of  their  source  with  cer- 
tainty. These  observations  are  so  incompatible  with  any  known  action 
of  microorganisms  that  it  is  impossible  to  regard  the  argument  of  the 
adherents  of  the  parasitic  theories  seriously. 

Satisfactory  as  is  the  basis  of  our  belief  that  it  is  the  cells  of  the  body, 
embryonal  or  adult,  which,  having  acquired  the  power  of  autonomous 
growth,  continue  to  develop,  it  is  much  more  difficult  to  explain  the 
methods  of  their  operation.  Embryonal  cells  which  lie  dormant,  it 
may  be  assumed,  retain  a  greater  power  of  development  than  cells 
that  have  become  fully  differentiated,  though  this  is  mere  assumption. 
Various  explanations  have  been  advanced  why  at  some  period  these 
cells  begin  to  assert  their  power  of  limitless  development.  Injury 
and  increased  nutrition  have  been  the  chief  causes  assigned.  It  would 
be  nearer  the  truth  to  assume  that  it  is  the  increased  nutrition  brought 
about  by  injury,  together  with  probably  the  absence  of  an  acidophilic 
basement  membrane.  It  is  to  explain  malignancy  in  fully  developed 
cells  that  our  chief  argument  must  be  directed.  We  have  acquired 
some  knowledge  as  to  why  cells  develop,  thanks  to  the  labors  of  Loeb,^ 
Hertwig,2  and  others;  but  we  are  ignorant  as  to  why  they  develop  in 
certain  directions  in  the  embryo  and  why  their  development  ceases  at 
a  certain  point.  Tissue  tension  is  a  term  which  is  employed  to  express 
the  balance  of  the  tissue  in  what  we  may  call  the  resting  state,  which 
controls  the  multipHcation  of  cells  and  maintains  their  physiological 
balance.  Direct  mechanical  control  of  cell  growth  in  some  instances 
seems  probable,  since  Loeb^  found  that  in  animals  tumors  which  had 
ceased  to  grow  began  again  to  grow  when  a  portion  was  transplanted 
to  another  region.  The  validity  of  this  argument  is  somewhat  lessened 
by  the  fact  that  not  only  was  the  tumor  released  from  the  mechanical 


1  Resume  and   lit.  Die  cliemische  Entwicklungserregung  des  tierischen  Eies,  Springer, 
Berlin,  1909. 

^  Die  Zelle  und  die  Gewebe,  Fischer,  Jena,  1893. 
^  Jour.  Med.  Research,  1901,  vi,  28. 


ETIOI.OC.Y  or   TIMfJkS  58 

i'i'sti;iiiil  lull  .ilsd  lioin  the  iiillii(in(  (jI  I<h.iI  i  iiiiiiiini  t  \  cxnti-d  1)\  llic 
tiiiiior.  (  )n  till  \\li()l(.  ilu-  ixtciii  (il  UK  (.Ikiiiu;!!  i(sti;iini  is  iiiuti  t  ;iin. 
I  lu-  (.•h;inL!,i'  tlu'  cells  iiiulci^,()  w  lu  ii  ilu\'  ;irr;iin  limitli-ss  jiioNsth 
ha\i'  hi-cii  (.•|()S(,I\  sriKlicd.  Changes  in  nnrosis  in  uliuli  rlic  nunihti 
and  aiianmnunt  ot  (.■Inoniosomcs  i"csi-nil)l(  ili(i\(  ot  ilic  licinimal  cells 
has  led  to  the  assuniprion  that  a  sort  ot  conjugation  takes  jiiace  he - 
tween  leiik()C\tes  and  tunioi  cells,  oi  hetween  leukocytes  and  normal 
cells,  or  hetween  various  normal  cvWs.  Ilu  division  of  cells  and  tlu 
arrangement  ot  chromosomes  is  not  iimtoiin,  and  iIk  iiansition  from 
the  normal  to  the  tumor  cell  is  not  as  ahru|')t  as  this  su|5|")osition  would 
make  necessary.  Hansemann  has  taken  these  \anations  in  nntosis 
into  account  to  explain  a  gradual  change  in  which  the  loss  of  certain 
elements  produces  cells  of  a  different  developmental  potential.  Ihese 
changes  too  are  too  inconstant  to  admit  them  as  a  causative  factor. 
They  seem  to  be  the  result  rather  than  the  cause  of  the  endless  pro- 
liferation. Ribbert's  hypothesis  of  "Riickschlag,"  which  assumes  an 
approach  to  an  undeveloped  state,  explains  the  disposition  to  prolifera- 
tion, but  does  not  explain  the  purposeless  growth.  The  attempt  to 
compare  tumor  cells  with  normal  cells  has  led  to  nothing  but  confusion, 
[he  tumor  cell  is  something  distinctive,  without  analogy  in  the  noinial 
organism. 

Oertel^  has  regarded  the  tumor  cell  as  an  e\idence  of  degeneration. 
Ewing-  regards  with  favor  this  conception  as  a  working  hypothesis. 
Carcinomas  occur  in  certain  organs  which,  as  a  whole,  have  undergone 
regression,  in  the  mammar}'  gland  for  example.  Study  of  these  cases 
shows  prirnarih'  changes  in  the  connective  tissue  and  also  often  changes 
in  the  character  of  the  epithelial  cells,  with  a  loss  in  secretory  function 
proportional  to  the  rapidity  of  the  growth.  These  phenomena  may 
possibly  be  regarded  as  evidence  of  degeneration,  but  the  cause  of  it 
does  not  appear.  It  is  of  interest  to  note  that  in  the  developing  gland 
the  power  of  growth  predominates,  but  with  the  appearance  of  the 
basement  membrane  the  power  of  growth  is  displaced  by  the  power 
of  secretion.  W  hen  the  basement  membrane  disappears,  proliferation 
again  exceeds  tiie  function  of  secretion. 

The  causes  which  bring  about  healing  when  a  tissue  is  partly  destroyed 
seem  closeh'  allied  to  the  causes  which  excite  tumor  growth.  My  own 
researches  have  convinced  me  that  the  basis  for  the  development  of 
fibrous  tissue  and  also  the  stimulus  to  the  production  of  the  epithe- 
lium depend  upon  the  presence  of  fibrin;  for  not  only  is  epithelial  cell 
proliferation  prevented  hy  those  means  which  prevent  the  formation 
of  fibrin,   hut  epithelial    cells    are   not   formed    over   granulations  wh.en 

*  New  "I'ork  Med.  Jour.,  IQ07,  Ixxxvi,  14.  -  Loc.  cir. 


54  THE  GENERAL  BIOLOGY  OF  TUMORS 

the  fibrin  stage  has  passed.  This  notion  is  in  harmony  with  the  revised 
theory  of  Ribbert,  the  result  of  the  changes  in  the  connective  tissue 
he  has  noted  being  to  produce  the  fibrin  stage.  The  exact  stages  are 
as  yet  unknown.  Nevertheless,  we  know  that  it  is  essentially  a  local 
disturbance  in  cellular  activity  by  which  cells  acquire  autonomous 
growth   resulting  from   some  disturbance  in  tissue  tension. 


INCIDENTAL   FACTORS    IN    TUMOR   FORMATION 

Age. — It  has  previously  been  mentioned  that  developmental  anom- 
alies may  be  manifest  as  congenital  tumors,  or  may  be  the  site  in  which 
tumors  develop.  It  is  of  interest  in  this  connection  to  note  that  con- 
nective-tissue tumors  are  more  prone  to  develop  in  early  life  than  are 
epithehal.  It  is  also  noteworthy  that  certain  organs  are  especially 
hkely  to  be  affected  in  early  life;  thus  the  eye  and  the  kidney  furnish 
the  most  frequent  seat  for  early  sarcoma,  while  it  is  the  gastro-intestinal 
tract,  particularly  the  rectum,  that  supplies  the  greatest  number  of 
carcinomas.  In  many  of  the  tumors  reported  as  occurring  in  early 
life,  particularly  as  carcinoma,  the  diagnosis  is  made  on  microscopic 
examination  alone,  without  regard  to  clinical  evidence  of  independent 
growth.  Congenital  structures  are  often,  no  doubt,  reported  as  carci- 
nomas or  sarcomas.  Those  tumors  which  have  not  manifested  the 
clinical  characters  of  malignant  growth  should  be  accepted  as  malignant 
with  reserve.  The  need  for  conservatism  is  well  indicated  in  the  recent 
discussion  of  so-called  carcinoma  of  the  appendix. 

Williams  has  recently  emphasized  the  important  fact  that  the  fre- 
quency of  malignancy,  as  also  general  mortality,  increases  with  advancing 
years,  and  that  carcinoma  mortality  increases  more  rapidly  than  general 
mortality  between  the  ages  of  forty-five  and  sixty-five,  and  thereafter 
less  rapidly,  suggesting  a  possible  relationship  between  carcinoma  and 
the  metabolic  processes  incident  to  the  sexual  decline. 

Taken  as  a  whole,  the  study  of  the  relationship  of  tumors  to  age 
periods  has  brought  certain  facts  chnically  useful  in  the  determination 
of  the  classes  of  tumors  likely  to  occur  in  particular  organs,  but  noth- 
ing has  been  learned  which  throws  any  light  on  the  causation  of  tumors. 

The  incidence  of  tumors,  according  to  age,  will  be  considered  with 
the  tumors  of  the  various  organs. 

Sex. — Sex  itself  is  not  known  to  exert  any  great  influence  upon  the 
formation  of  tumors.  Women  are  more  often  affected  by  carcinoma 
than  men,  in  the  proportion  of  three  to  two,  but  this  is  because  they 
have  organs  peculiarly  susceptible  to  influences  associated  with  the 
production  of  maHgnant  growths.     Aside  from  the  tumors  of  the  genera- 


77//.  i<i:i..ni()\  oi  srrA.iiic  I  \  iiA:-ri(j\   ro  timoks  oo 

ri\'c-  ()m.;iii.s,  iiuIiulmLl,  the  m.iiimi.ii\  ^l.iiuls,  llic  ivso  sexes  :ire  iihout 
c(iu;ill\  aHectccl,  s;i\c  loi  ;i  pi  cpoiuKi  ;i  luc  of  lintiiu  mia  i)t  the  lip, 
Miourh,  ami  throat   in  t  hi-  male. 

Heredity.  I  he  histoi\  th.scloses  the  existence  of  tumors  in  other 
members  of  tin  lamil\  m  about  20  per  ei-nt.  of  the  cases.  Williams" 
statistics,  co\  iiiiiii,  370  carcinomas  in  wonun,  show  hereditaiv  possi- 
bilities in  S3  (22.4  per  cent.).  l>iithn  estimates  thai  about  oiu-tbird 
give  a  carcinomatous  family  histoi\  .  Recent  fij^ures  l)\  the  Middlesex 
Hospital'  fi;ive  only  S  per  cent.  This  ti<;uii'  represents  the  percentage 
m  which  a  direct  transmission  from  either  parent  might  be  assumed. 
It  IS  worth  noting  that  in  the  histories  of  patients  where  tumors  are 
not  m  (|uesti()n  a  considerable  proportion  will  be  found  to  possess 
tumorous  ancestrw  I  lowever,  there  are  families  in  which  carcinomas 
occur  with  striking  frequency.  If  the  probabilit\-  of  error  in  diagnosis 
be  taken  into  account,  the  percentage  of  the  positive  existence  of  carci- 
noma in  ancestry  probably  would  be  reduced.  The  occurrence  of  non- 
malignant  tumors,  especialh'  moles,  Hbromas,  and  neuromas,  in  certain 
families  has  been  noted.  It  ma\-  be  stated  tentatively  that  heredit\ 
exerts  a  slight  influence  in  the  production  of  tumors.  It  might  be  due 
to  direct  displacement  of  embryonal  tissue  (embryomas)  or  to  trans- 
mission of  the  exciting  factors  (Wolf),  or  to  heightened  \ita!it\  of 
epithelial  cells. - 

Influence  on  Nutrition  of  Tumor  Formation.  It  is  interesting  to 
note  that  while  approximately  2  per  cent,  of  malignant  tumors  are 
found  on  the  extremities,  their  occurrence  upon  paralyzed  limbs  is  prac- 
tically unknown.  Statistics  relative  to  general  nutrition  are  conflicting, 
but  in  general  it  ma}^  be  stated  that  it  is  the  physicall)'  vigorous  that 
are  particular!}'  predisposed.  The  imbecile  and  insane  are  but  little 
subject  to  malignant  disease. 

THE  RELATION  OF  SPECIFIC  INFECTION  TO  TUMORS 

Tuberculosis. — Carcinomas  have  been  reported  as  occurring  in  lupous 
ulcers  and  in  tuberculous  scars.  Rokitansk}'  regarded  the  two  processes 
as  mutuall}'  exclusive,  while  Ribbert  believes  that  tuberculous  processes 
act  directly  as  an  excitant  of  epithelial  proliferation  by  isolating  epi- 
thelial islands.  Not  infrequentl\',  giant  cells  are  seen  in  or  about 
epitheliomas,  but  these  are  more  satisfactorily  explained  as  foreign 
body  giant  cells.  They  resemble  foreign  bod}'  giant  cells  histologicall}', 
and   tubercle   bacilli   have  not   been  demonstrated   in  them.       Ihat  two 

'  Arch.  Middlesex  Hospital,  1904,  ii,  104;  190^,  \',  103. 

'Alberts,  Das  Carcinom  in  Histologischer  und  experinieiitell  pathoiotiisclier  Bezie- 
luing,  Fischer,  Jena,  1887,  p.  53. 


56  THE  GENERAL  BIOLOGY  OF  TUMORS 

such  common  maladies  as  carcmoma  and  tuberculosis  should  occur 
simultaneously  cannot  create  surprise.  The  actual  occurrence  of  the 
two  diseases  together  is,  however,  surprisingly  rare,  probably  because 
the  maxima  of  frequency  of  the  two  diseases  fall  at  different  ages. 
Frequently  at  autopsies  of  carcinoma  patients,  evidence  of  healed 
tuberculosis  is  found.  That  carcinoma  is  less  frequent  in  tuberculous 
subjects  than  in  non-tuberculous,  as  is  shown  by  statistics  of  Lubarsch,' 
is  not  fully  explained  by  their  different  age  incidence,  and  it  seems 
probable  that  there  is  some  antagonism  between  the  two  diseases. 
It  might  be  assumed  that  the  tuberculous  process  excites  an  active 
resistance  on  the  part  of  the  connective  tissues  which  tends  to  restrict 
rather  than  to  invite  the  proliferation  of  epithelium. 

The  relation  of  sarcoma  to  tuberculosis  is  more  difficult  to  define 
because  of  the  close  resemblance  of  granulation  tissue  to  sarcoma  and 
because  of  the  clinical  similarity  of  the  two  diseases.  This  latter  feature 
makes  it  doubly  important  that  the  scientific  study  of  this  problem 
should  be  undertaken  with  caution.  Confusion  between  the  two  has 
been  particularly  great  in  certain  lymph  gland  diseases.  To  prove 
any  relationship  there  must  be  demanded,  on  the  one  hand,  the  demon- 
stration of  the  tubercle  bacillus,  and  on  the  other  hand,  evidence  of 
the  sarcomatous  nature  as  manifested  in  the  clinical  course.  Animal 
inoculation  of  questionable  material  should  demonstrate  the  bacilli 
if  present.  In  the  face  of  negative  results  a  positive  opinion  should 
be  held  in  reserve  irrespective  of  the  microscopic  appearance  of  the 
lesion.  If  this  extreme  caution  be  observed,  the  causal  relationship 
between  tuberculosis  and  sarcoma  cannot  be  admitted. 

Syphilis. — The  possible  causal  relation  between  carcinoma  and 
syphihs  is  limited  to  the  occurrence  of  epitheliomas  in  syphilitic  scars. 
In  these  cases  there  is  no  evidence  that  the  specific  nature  of  the  scar 
played  any  part,  but  rather  that  the  scar  tissue  acted  merely  as  such 
tissue  occasionally  does,  irrespective  of  the  cause  of  the  primary  wound. 
Extensive  epithelial  proliferation  is  sometimes  seen  about  syphilitic 
processes,  but  it  differs  in  no  way  from  similar  processes  about  any 
ulcer. 

The  histological  resemblance  of  syphilis  to  sarcoma  is  m  certain 
rare  instances  very  perplexing;  in  fact,  the  microscopic  evidence  in 
such  cases  cannot  be  regarded  as  decisive.  The  therapeutic  test  for 
syphilis  is  distinctive  in  most  cases  and  the  recent  specific  reactions 
for  this  disease  may  serve  to  clear  up  some  doubtful  cases.  At  present 
no  relationship  between  the  two  conditions  can  be  accepted. 

Other  disturbances,  such  as  bilharzia,  are  sometimes  followed  by 
carcinoma.  The  action  of  the  parasite  is  probably  merelj^  that  of  a 
chronic  irritant. 

^  Virchow's  Arch.  f.  path.  Anat.,  1888,  cxi,  305. 


P  A  R  r    II 

THE  SPECIAL   PATHOLOGY   OF  TUMORS 

CHAPTER   I 
OSTEOMAS 

General  Conception.  1  umors  which  develop  from  bone  are,  like 
those  from  cartilage,  usually  reactive  in  nature,  the  result  of  some 
directl}'  traceable  irritation.  The  border-line  between  these  and  true 
tumors  is  often  difficult  to  draw.  In  addition,  bone  formation  is  some- 
times found  in  true  tumors  which  are  for  the  most  part  of  a  different 
character,  notably  sarcomatous.  When  all  these  are  excluded  there 
remains  a  group  of  rare  tumors  which  may  rightl}'  be  regarded  as  true 
osteomas. 

True  Osteomas. — These  may  be  derived  from  the  periosteum  or 
from  the  medulla.  In  structure  the}'  may  be  dense  or  cancellated. 
When  periosteal  they  form  nodular  or  globular  projections  from  the 
surface  of  the  bone  and  are  covered  by  a  vascular  periosteum.  Those 
arising  in  the  medulla  expand  the  bone  or  cause  it  to  disappear  by 
pressure  atrophy.  Usuall}'  in  response  to  the  expanding  bone  the 
periosteum  proliferates  actively  so  that  new  bone  is  formed  over  the 
expanding  tumor.  This  may  disappear  and  the  tumor  ma}'  project 
into  the  soft  tissues.  This  type  occurs  most  frequentl}"  in  the  long 
bones  and  in  the  bones  of  the  face. 

Macroscopic  Appearance, — The  surface  when  denuded  of  periosteum 
does  not  differ  essentiall}'  from  normal  bone.  The  dense  varieties 
are  vet}"  white  in  color,  while  the  more  spong}'  varieties  are  reddish 
brown.  In  the  former  there  are  no  openings  for  the  passage  of  vessels, 
while  in  the  latter,  numerous  and  often  large  foramina  ma}'  be  seen. 
The  t\pe  of  tumor  ma}'  thus  be  distinguished  b}'  inspecting  the 
unbroken  surface.  On  section,  the  dense  variet}'  closel}'  resembles  in 
appearance  sawed  ivor}',  while  in  the  softer  t}'pes  the  cortex  often 
presents  the  appearance  of  cancellated  bone,  while  the  centre  ma}'  be 
formed  b\'  a  pulp}'  mass  resembling  medullar}'  tissue,  with  here  and 
there  bone  spicules. 


58  OSTEOMAS 

Microscopic  Appearance. — Sections  of  decalcified  osteomas  closely  re- 
semble normal  bone  (Fig.  9).  Haversian  canals  are  present,  but  they 
are  not  arranged  in  systems  (Fig.  10).  The  cells  vary  more  than  in 
normal   bone;   they   are  often  larger,   and   many  are  multinuclear.      In 


Fig.  9 


V    ,V.)- 


.f  ■> 


:>■" 


Osteoma. 

the  cancellated  variety,  cells  resembling  those  of  normal  medulla  may 
be  seen  in  great  numbers,  and  the  intertrabecular  spaces  are  larger 
than  in  the  normal. 

Growth. — Osteomas   are  expansile  and  benign.     When  they  are  asso- 
ciated   with    mahgnant    conditions,    as    is    often    the    case,    microscopic 

Fig.  10 


Osteoma  of  the  humerus,  showing  Haversian  canals. 

Study  of  their  character  may  be  inconclusive;  but  the  rate  and  char- 
acter of  growth  often  makes  an  accurate  judgment  possible. 

Varieties. — Osteomas  are  often  associated  with  cartilage,  and  in 
many  situations  are  usually  covered  by  it;  but  here  the  presence  of 
the  cartilage  is  as  much  a  part  of  the  developmental  process  as  is  the 


I'lLSE  osriioM.is  50 

fiu  ilopiiiL!,  |)ii  lositiim  m  oilui  Ml  ii;i  I  lolls.  hi  nilni  cases  the  cliai- 
acttM"  ot  tin-  i;,i()\\ili  is  that  dI  romhincd  rlioiulioma  and  osteoma  ami 
rile  teiin  chomlKx'isrioma  shoiiM  \n-  lesei  \e(l  lot  this  eomhrion.  I  his 
illsrimtion  is  of  impoiraiuc-,  siiuc  thi-  eomhim-d  rumor  is  of  (httereiu 
im|>ort  from  those  m  wimh  eaitihii^e  a|)peais  meiil\  as  a  sta^eol  descl- 
opmeiu.  The  eoml^ined  cartilage  and  bony  tumors  ai(  olreii  associared 
wirh  activeh  pi oHferarinj;  connecrive  rissue,  and  the  chondro(")sreo- 
sarcoma  iisulrs.  The  demonstrarion  of  rhe  Hrsr  rwo  elements  m  a 
lajiidh  uiowini:,  tumor  ofrtn  wananrs  the  assumprion  ot  rhe  jiresence 
of  the  third  element.  When  Hhious  tissue  is  present  m  an  osteoma, 
it  ma\-  he  regarded  as  an  accidental  admixture,  while  myxoid  tissue  is 
the  resulr  of  degeneration. 

False  Osteomas. — These  are  bony  outgrowths  which  are  not  the 
result  of  true  neoplastic  bone  formation.  They  ma\-  result  from  trauma 
or  from  chronic  irritation,  either  mechanical  or  inflammator\-.  Dis- 
turbances in  normal  development  may  result  in  the  formation  ot  bon\ 
excrescences  about  the  epiphyseal  lines.  These  are  often  multiple, 
and  when  symmetrical  are  described  under  the  term  exostosis  cartila- 
genia.  This  condition  is  brought  about  by  the  direction  of  growth 
at  the  epiph^'seal  line  being  transverse  instead  of  parallel  to  the  long 
axis  of  the  bone,  with  the  result  that  the  bone  fails  to  develop  in  length. 
These  growths  ma^'  appear  less  typically  in  other  situations.  1  hex- 
have  been  observed  at  birth,  and  frequently  the\-  appear  or  undergo 
more  rapid  development  at  pubert}'.  Dwarf  development  or  mal- 
development  of  a  part  is  often  found  in  connection  with  them.  In 
other  situations,  bony  tumors  are  obviously  the  result  of  metaplasia 
of  displaced  cartilage,  which  is  most  often  found  about  the  trachea  and 
its  branches  and  in  the  deeper  parts  of  the  lungs,  about  the  ears,  in 
the  tonsils,  and  about  the  site  of  the  gill  clefts.  Exostoses  are  observed 
about  joints  in  a  great  variety  of  joint  lesions.  They  may  occur  about 
the  vertebral  disks.  A  special  name  has  been  applied  to  exostosis  \n 
the  sphenooccipital  articulation  (the  clivus  Blumenbachii),  namely, 
chordomas.  Bone  occasionally  develops  as  a  result  of  inflammatory 
process  in  tissues  normall\-  free  from  bone,  as  in  muscle  in  myositis 
ossificans. 

Diagnosis. — The  character  of  the  tissue  is  easily  recognized.  '1  he 
differentiation  between  true  and  false  osteomas  is  often  difficult  and 
subject  to  different  interpretations.  The  character  and  circumstances 
of  the  growth  may  permit  a  distinction.  The  microscopic  differentia- 
tion  between   these  and  osteosarcomas  is  often  ditlicult  or  impossible. 

Treatment. — Excision  is  indicated  when  their  situation  or  size  causes 
annoyance.  Osteomas  of  the  medullary  t\pe  ma)-  require  the  removal 
of  some  normal  bone  before  access  can  be  had  to  them. 


CH APTE  R  I  I 

CHONDROMAS  AND  CHORDOMAS 

CHONDROMAS 

General  Conception. — Tumors  composed  wholly  or  in  part  of  cartilage 
are  not  uncommon.  Cartilage  occurs  most  frequently  as  a  component 
of  certain  mixed  tumors  which  are  best  considered  as  a  separate  group. 
Trauma  sometimes  results  in  cartilage  proliferation  of  limited  growth. 
This  IS,  strictly  speaking,  an  hj^pertrophy  and  is  usually  grouped  sepa- 
rately under  the  term  ecchondrosis.  When  these  cartilaginous  tumors, 
because  of  their  origin  or  nature,  are  excluded,  there  still  remains  a 
group  which  is  classed  under  the  head  of  true  chondromas  or  enchon- 
droses. 

False  Chondromas. — The  ecchondroses  or  ecchondromas,  as  they  are 
more  properly  called  when  they  are  large  enough  to  form  tumor  masses, 
are,  strictly  speaking,  local  hypertrophies.  They  seldom  attain  a  size 
large  enough  to  make  them  of  practical  significance.  They  occur  at 
the  site  of  the  normal  cartilage  and  are  caused  by  some  disturbance 
in  normal  development,  or  perhaps  by  injury  which  produces  a  local 
overgrowth  analogous  to  hypertrophied  scars  in  wounds  of  the  con- 
nective tissue.  They  are  composed. of  tissue  approaching  that  of  normal 
cartilage  and  may  contain  bone  at  their  base. 

True  Chondromas  (Enchondromas). — Tumors  formed  entirely  of 
cartilage  have  been  described  at  a  distance  from  bone.  Those  which 
occur  in  organs  where  mixed  tumors  are  known  to  exist,  as  in  the  salivary 
glands,  testicles,  and  breasts,  are  most  satisfactorily  considered  as 
mixed  tumors  in  which  the  other  elements  have  been  either  compressed 
by  the  growing  cartilage,  or  overlooked  in  the  examination.  Many 
of  those  described  in  the  older  literature  were  not  subjected  to  micro- 
scopic examination  at  all.  Other  purely  cartilaginous  tumors  have 
been  described  which  were  connected  neither  with  bone  nor  with  organs 
in  which  mixed  tumors  arise. 

In  contradistinction  to  these  are  the  tumors  of  cartilage  which  spring 
from  bone  or  cartilage  or  from  their  immediate  vicinity.  When  not 
directly  continuous  with  cartilage  or  bone  they  are  derived  from  meta- 
morphosed connective  tissue  or  from  misplaced  embryonal  tissue. 
Their  origin  from  the  latter  source  seems  more  probable,  both  on  account 


CllOSDROM.IH  CI 

of  tlu-  {ifciiKiu  association  ot  tartihi^.f  witli  rumors  known  ro  l)c  con- 
genital, and  also  on  account  of  tluir  frc-qiKnt  aj^iHarance  after  injur)  . 
These  tumors  are  found  most  frequently  on  the  diaph\ses  of  the  ion^ 
bones  near  the  epiphyseal  lines,  especially  of  the  hands,  feet,  clavicle, 
pelvic  hones,  and  rihs,  though  none  of  the  bones  are  invariablv  spared. 
Macroscopic  Appearance.  Chondromas  are  dense  tumors,  usualh'  with 
smooth  or  nodulated  surfaces,  and  are  generally  encapsulated.  Their 
cut  surface  is  smooth,  glistening,  and  hluish  in  color.  Frequently, 
fibrous  bands  extend  for  some  distance  into  the  tumor  and  convex* 
bloodvessels.  Not  infrequently  ossihed  areas  and  various  degenera- 
tions are  encountered. 

Fig.  II 


e 


\ 


k   1    " 


c 


•  V 


*s 


■■•J 

Chondroma  of  finger. 

Microscopic  Appearance. — A  section  presents  the  appearance  usually 
quite  t3'pical  of  cartilage  i  Fig.  ii).  The  interstitial  tissue  stains  blue 
with  hematow'lin  and  reddish  \'ellow  with  safranin.  The  cells  may 
occur  singh'  or  in  groups  of  two  or  more;  frequently  in  large  groups. 
They  are  often  of  various  sizes  and  may  lack  a  capsule.  The  variation 
in  cells  is  the  most  important  deviation,  and  forms  the  chief  index  to 
the  biological  character  of  the  tumor  (Fig.  12).  Large  areas  ma}'  be 
seen  devoid  of  cells  (Fig.  12).  Fibrils  are  often  apparent  in  the  inter- 
cellular substance,  and  are  often  continuous  with  fibrils  about  the  cells. 
The  microscopic  appearance  of  chondroma  is  often  little  indicative  of 
the  character  of  the  tumor.  Tumors  containing  few  cells  may  grow- 
rapidly  and  may  invade  the  surrounding  tissue. 

Growth. — The  chondromas  frequently  become  stationary-,  but  may 
attain  a  considerable  size,  so  as  to  become  a  serious  menace  to  the 
activit}-  of  the  individual.     The  growth  takes  place  centralh'  and  the 


62  CHONDROMAS  AND  CHORDOMAS 

surrounding  tissue  is  displaced.  Occasionally  outgrowths  take  place  at 
the  periphery,  which  may  grow  into  a  vein  and  metastasis  may  result. 
These  metastases  are  like  the  mother  tumor,  composed  of  cartilage, 
and  are  especially  likely  to  occur  in  the  lung.  The  growths  may  be  so 
extensive  that  the  skin  covering  it  becomes  necrosed,  thus  exposing 
the  tumor  to  infection.  The  entire  bone  about  which  they  grow  may 
be  displaced. 

Fig.  12 


V '  ■;  \. 


Metastatic  chondroma  of  the  lung,  with  large  cells  and  very  small  nuclei. 

Secondary  Changes. — The  intercellular  substance  often  calcifies,  indi- 
cating the  existence  of  a  previous  degeneration.  Often  there  is  softening 
of  the  intercellular  substance,  which  may  give  place  to  liquefaction  and 
thus  produce  a  cyst. 

Varieties. — Combinations  with  other  tissue  are  not  infrequenth'  seen. 
Myxochondromas  are  not  rare,  and  osteochondromas  are  often  seen. 
The  natural  disposition  for  cartilage  to  form  bone  appears  hardly  to 
warrant  the  classification  of  these  as  compound  tumors,  but  often 
they  tend  more  than  simple  chondromas  to  malignant  transformation. 
The  most  important  combination  of  chondromas  is  with  sarcoma  in 
the  chondrosarcoma.      The  disposition  to  sarcomatous  proliferation  is 


CHORDOM.IS  03 

b\'  no  iiuaiis  rare-;  it  is  iliaiactti  i/cd  h\  i;i|)icl  jiiowrh  with  :i  rtndenc)' 
ro  unasioii  i  set.-  Saiconia  ). 

Developmental  Malformations.  Nor  inhcciucnrlv  ,  as  a  rtsiilr  ot  some 
disriirhaiKt  in  (growth,  cartilaginous  excrescences  are  formed  about 
joints,  limiting  their  movements.  The  most  marked  of  these  is  the 
exostosis  cartilagenia,  which  was  mentioned  also  under  the  discussion 
of  osteomas.      Rickets  and  s\phihs  may  give  rise  to  similar  conditions. 

Congenital  Displacements.  In  many  of  the  mixed  tumors  cartilage  is 
an  important  element.  Ihis  is  true  particularly  of  those  occurring  in 
the  salivarx'  glands  and  in  the  testicle,  as  already  mentioned.  Isolated 
islands  of  cartilage,  without  the  usual  accompaniments  characterizing 
mixed  tumors,  have  been  found  and  the  question  has  arisen  as  to  their 
nature.  Some  pathologists  classify  them  w^ith  congenital  displace- 
ments, while  others  regard  them  as  examples  of  metaplasia.  1  he  fact 
that  the\"  occur  in  regions  in  which  cartilage  normally  occurs  (trachea) 
or  where  mixed  tumors  are  common  (neck,  ear)  makes  it  seem  probable 
that  thev  are  congenital  displacements.  It  is  rarely  that  the\'  undergo 
further  development. 

Prognosis. — Chondromas  are  benign  tumors,  but  their  frequent  asso- 
ciation with  mixed  tumors,  which  are  liable  to  malignant  change,  and 
with  sarcomas  makes  the  determination  of  the  exact  nature  of  a  cartilage 
tumor  a  matter  of  some  concern.  Those  which  occur  on  the  fingers 
and  toes  are  usual!)'  permanenth'  innocent,  but  those  which  arise  about 
the  epiph^'ses,  and  particularly-  those  which  appear  following  trauma, 
often  necessitate  a  guarded  prognosis.  Those  which  develop  rapidlw 
even  if  careful  examination  fails  to  show  an\-  evidence  of  malignance", 
must  be  regarded  with  suspicion. 

Treatment. — The  rapidly  growing  tumors  require  removal  because 
of  the  uncertainty  of  their  character  and  because  of  their  size.  Those 
of  the  hands  and  feet  require  removal  because  of  the  interference  with 
the  function  of  these  parts. 

CHORDOMAS 

According  to  Ribbert,'  tumors  springing  from  the  remains  of  the  noto- 
chord  are  to  be  noted  in  about  2  per  cent,  of  all  autopsies  at  the  spheno- 
occipital synchondrosis  (the  clivus  Blumenbachii).  The  dura  is  some- 
times perforated  and  the  tumor  lies  upon  or  near  the  basilar  artery. 
The  cells  are  spheroidal  with  deeply  staining  nuclei  and  with  clear 
protoplasm.  Minot  regards  them  as  epiblastic  in  origin,  while  Adami- 
regards  them  as  hypoblastic. 

1  Centralbl.  f.  Path.,  1894,  v,  457. 

^The  Principles  of  Pathology,  Lea  &  Febiger,  Philadelphia,  vol.  i,  p.  761. 


CHAPTER     III 
MYXOMAS 

Myxomas  are  the  most  embryonal  of  the  benign  connective-tissue 
tumors  just  as  myxoid  tissue  is  the  preliminary  stage  of  connective 
tissue. 

Topography. — These  tumors  have  been  observed  wherever  there 
is  connective  tissue,  particularly  in  the  subcutaneous  tissue  of  the 
back  and  thigh,  less  often  in  the  face,  genitals,  nerves,  and  medullary 
cavities  of  bones.  Usually  they  occur  in  conjunction  with  other  tissues, 
particularly  in  various  tumors  where  the  nutrition  is  insufficient,  such 
as  myomas  and  fibromas;  or  in  tumors  growing  from  mucous  surfaces, 
uterus,  nose,  or  pharynx;  or  develop  in  the  presence  of  moisture,  as 
in  the  spinal  cord;  or  are  the  results  of  developmental  anomalies,  as  in 
mixed  tumors  of  the  breast  and  parotid. 

Macroscopic  Appearance. — Myxomas  form  spheroidal  tumors  when 
small,  but  when  large  are  often  lobulated.  They  are  soft,  semifluctuating, 
and  on  section  are  pinkish  white  and  moist  or  succulent,  often  with 
vessels  apparent. 

Microscopic  Structure. — The  matrix  is  clear  and  translucent,  and 
yields  a  granular  or  fibrillar  precipitate  upon  the  addition  of  acetic 
acid.  The  typical  cells  are  stellate  with  anastomosing  branches,  but 
some  may  be  round  or  spindle-shaped  (Fig.  13).  The  vessels  are  large 
and  numerous  and  are  often  surrounded  by  groups  of  round  cells 
(Fig.  14)  believed  by  some  to  be  the  mj^xoid  cells  in  the  course  of 
development. 

Mixed  Forms. — Pure  myxomas  are  very  rare.  They  are  usually 
associated  with  fibrous  tissue  and  less  often  with  fatty  tissue.  With 
these  tissues  they  form  combinations  in  varying  proportions,  but  usually 
the  myxoid  tissue  predominates.  When  the  reverse  is  true,  the  myxoid 
tissue  is  probably  a  degeneration  product.  Embryonal  fibrous  tissue 
particularly  is  Ukely  to  be  associated  with  myxoid  tissue.  Such  tumors 
are  especially  likely  to  develop  malignant  tendencies  marked  by  per- 
sistent local  recurrence  and  finally  by  metastatic  formations.  It  is 
only  when  the  myxoid  tissue  is  an  active  factor  that  a  compound  term 
is  applicable,  as  myxofibroma,  myxolipoma.  The  presence  of  stellate 
cells,  particularly  if  the  branches  anastomose,  has  been  said  to  be  evi- 
dence that  the  myxoid  tissue  is  taking  an  active  part,  but  this  is  by 
no  means  an  infallible  sign. 


MIXIJ)  KjRMS 


05 


Myxoid  tissue,  as  most  frecjiit-ntly  observed  in  tumors,  is  the  result 
of  def^eneration,  and  is  ^enerall\'  observed  in  tumors  where  nutrition 
IS  detective  and  often   is   but  one  step   in   the   regressive  prcjcess,   beinji 


a 


4 


Fig.  13 
9 


q> 


si 


^ 


t 


«r 


^'  •  ■^'  # 


^T-',y-: 


\>^0^'~ 


:m^^ 


Myxoma  of  the  elbow. 
Fig.  14 


4->®l? 


;.y%v       .rS.^J^T^~' 


A  /  i'-  -      . . 


.  .-j<  -  *  *  ' 

Myxoma  showing  cells  about  bloodvessels. 

followed  in  turn   by   hemorrhage  and   cyst   formation.      In  other  cases 
the  occurrence  of  myxoid  tissue  is  but  the  result  of  the  conditions  of 
growth,  as  in  nasal  polyps,  and  it  is  often  difficult  to  determine  if  the 
5 


66  MYXOMAS 

changes  in  the  tumor  are  really  myxoid  or  merely  the  result  of  edema. 
Often  the  clinical  character  of  the  tumor,  and  the  gross  appearance, 
may  aid  in  arriving  at  a  conclusion;  but  in  some  instances,  as  in  the 
uterus,  when  edema  and  myxomatous  degeneration  are  often  present, 
these  considerations  give  little  aid;  indeed,  it  seems  that  a  prolonged 
edema  may  institute  myxoid  changes  within  the  connective  tissue.  The 
determination  of  these  points  is  often  more  than  an  academic  problem; 
for  instance,  the  myxoid  tissue  may  be  but  the  preliminary  step  in  a 
series  of  changes  resulting  ultimately  in  the  development  of  sarcoma. 

Degeneration. — Hemorrhage  is  said  to  be  a  frequent  complication. 
This  is  true  when  myxomatous  degeneration  takes  place  in  tumors 
of  other  composition,  but  m  tumors  in  which  the  myxoid  tissue  is  an 
active  factor,  hemorrhage  does  not  take  place  with  readiness  because 
the  vessels,  though  large,  have  well-defined  walls. 

Diagnosis. — The  soft  circum.scribed  encapsulated  tumors  are  often 
distinguished  from  fibromas  and  lipomas  by  the  aid  of  palpation,  but 
usually  a  gross  section  of  the  tumor  is  required  before  a  dijfferentiation 
is  positive.  The  succulent  jelly-like  tissue  is  then  easily  identified.  If 
the  myxoid  tissue  is  an  active  factor  the  entire  tumor  is  of  like  com- 
position, while  if  it  is  but  a  degeneration  product,  only  part  of  the 
cut  surface  presents  that  appearance.  Whether  a  pure  myxoma  or  a 
compound  tumor  is  in  hand  the  microscope  must  often  be  relied  upon 
to  decide. 

Treatment. — The  small  myxomas  are  innocent  and  a  simple  enu- 
cleation is  sufficient.  When  large  or  rapidly  growing,  the}^  must  be 
regarded  with  suspicion;  their  capsule  should  be  removed  with  the 
tumor,  and  every  care  exercised  that  the  small  lobulations  and  pro- 
longations be  thoroughly  removed.  This  is  particularly  imperative 
in  tumors  of  the  face,  back,  and  thigh. 


r  II  A  VJ  V.  R     I  V 

LIPOMAS 

Tumors  composed  of  fatty  tissue  are  common  objects.  iliey  are 
found  wherever  fatty  tissue  occurs  normal!}',  particularl\  in  the  sub- 
cutaneous tissue,  but  also  in  unusual  refi;ions,  as  in  the  marrow  ot  bones, 
beneath  rhi  periosteum  ;in(l  in  the  meninges.  In  these  exceptional 
situations  the\-  are  merely  pathological  curiosities.  Cjenerall\'  increased 
fatt\-  deposits  are  sometimes  noted,  the  most  familiar  ot  these  being 
lipomatosis  dolorosa,  a  condition  first  described  b\-  Dercum  in  which 
the  general  increase  of  fat  is  attended  by  pain.  Multiple  fatty  tumors 
in  the  course  of  certain  nerves  are  sometimes  noted.  Nervous  mflu- 
ences,  therefore,  as  in  the  case  of  those  hbromas  which  are  smidarly 
situated,  seem  to  be  associated  with  their  genesis. 

Macroscopic  Appearance. — Lipomas  are  spheroidal  or  lobulated 
tumors  varying  from  microscopic  size  to  enormous  masses  w'hich  are 
exceeded  by  no  other  solid  tumors.  As  ordinarily  encountered  the\- 
var}-  from  the  size  of  a  hazelnut  to  that  of  an  adult  head.  They  are 
usually  composed  of  a  number  of  lobules  each  more  or  less  perfectly 
encapsulated,  while  the  entire  tumor  is  similarly  encapsulated  agamst 
the  surrounding  tissue.  In  some  instances  lipomas  are  more  infiltra- 
tive in  character,  and  fine  tongues  of  fattA'  tissue  are  sent  m  between 
muscle  bundles  or  between  bloodvessels.  On  section,  lipomas  are 
moist  and  \ellow,  and  globules  of  fat  stand  out  prominently  over  the 
cut  surface.  The  tumors  are  divided  off  into  separate  lobules  by  fibrous 
septa  in  which  the  bloodvessels  run.  In  some  instances,  fibrous  tissue 
maA'  be  abundant. 

Microscopic  Appearance.— The  fat  globules  in  lipomas  are  char- 
acterized, as  opposed  to  normal  fat,  b\  a  variation  in  size  of  the  mdi- 
vidual  globules.  Otherwise  the  relations  of  cell,  nucleus,  and  fat  globule 
conform  to  the  normal;  as  also  do  their  relations  to  the  fibrous  tissue 
and  bloodvessels. 

Course. — Lipomas  tend  to  increase  in  size.  The  growth  is  usually 
slow  but  may  be  quite  rapid.  They  usually  are  of  no  clinical  impor- 
tance except  from  their  size.  In  most  cases  even  large  ones  may  be 
well  borne,  since  these  usually  occur  about  the  shoulders  or  back.  But 
even  if  they  do  occur  in  the  neighborhood  of  important  structures 
their  softness  prevents  compression. 


68  LIPOMAS 

Diagnosis. — Lipomas  are  the  easiest  tumors  to  recognize,  whether 
by  the  naked  eye  or  with  the  microscope.  The  only  question  is  to 
determine  if  the  fatty  tissue  is  primary  or  the  result  of  degeneration 
of  other  tissue.  Usually  if  other  tissue  is  present  the  latter  is  true; 
for  fatty  tissue  rarely  develops  along  with  other  tissue. 

Treatment. — Local  enucleation  is  best  performed  as  soon  as  the 
tumors  are  recognized,  since  they  tend  to  increase  in  size. 


C  II  A  PT  F.  R    \' 
MYOMAS 

Each  variet\'  of  muscle  Hhers  is  siihitcr  to  tumor  formation.  I  he 
vast  majority  of  myomas  are  the  product  of  tlu-  non-stnated  muscle 
and  are  called  leiomyomas.  Rhabdomyomas,  tumors  which  arise  from 
striated  muscle,  are  very  rare. 

Leiomyomas.  In  these  tumors  the  normal  non-striated  muscle  cell 
is  frequentl)-  accurately  reproduced.  They  develop  in  an\  region  where 
non-striated  muscle  normally  occurs,  hut  show  an  esprcial  pii-dikction 
for  the  uterus.  The  gastro-intestmal  tract,  the  prostate  ^land,  and  the 
skin  are  much  more  rarely  affected. 

Macroscopic  Appearance.  -The  tumors  are  spherical  oi  noduhir  m  out- 
line, sharpl\  circumscribed,  and  usually  very  dense.  On  section  the 
knife  creaks  in  the  denser  varieties,  and  in  even  the  softer  varieties 
meets  more  resistance  than  in  normal  non-striated  muscle.  The  reason 
for  this  is  that  pure  niA'omas  are  very  rare,  there  being  usually  an  accom- 
panying increase  in  the  fibrous  tissue,  and  it  ma^-  even  predominate; 
whence  the  term  fibromyomas  or  fibroids  often  applied  to  such  tumors 
in  the  uterus.  The  cut  section  is  whitish  or  pinkish,  dependent 
upon  the  proportion  of  fibrous  and  muscular  tissue  respectively.  The 
peripherA'  is  usually  formed  largel\'  or  entirel\-  of  fibrous  tissue  in 
w'horls  or  bundles  which  run  in  various  directions.  For  this  reason 
some  bundles  are  cut  longitudinally,  others  transversely,  and  others 
obliquely.     Occasionally  the  lumina  of  bloodvessels  can  be  made  out. 

Microscopic  Appearance. — The  cells  of  these  tumors  resemble  normal 
non-striated  muscle  cells  very  closel)'.  The  nuclei  are  long  and  spindle- 
shaped,  and  are  surrounded  by  the  protoplasm  of  the  elongated  muscle 
fibers.  The  outline  of  the  fibers  is  best  appreciated  in  the  teased  speci- 
mens. When  a  muscle  bundle  is  cut  obliquel}-  the  cells  appear  as  short 
spindles,  and  when  cut  transversely  the}-  simulate  round  cells  (Fig. 
15).  In  the  more  rapidh'  growing  tumors  the  nuclei  are  broader  and 
larger  and  stain  less  deeply.  The  cells  are  arranged  parallel  to  the 
smaller  vessels,  but  indifferentl}-  in  respect  to  the  larger  vessels.  1  he 
proportion  of  fibrous  tissue  to  muscle  tissue  varies  considerably,  but 
is  usually  greater  than  in  normal  muscle.  The  differentiation  may 
not  be  plain  unless  special  stains  are  empkned.  With  the  van  Gieson 
stain  the  connective  tissue  appears  as  a  brilliant  red,  while  the  muscle 


70  MYOMAS 

stains  yellow.  The  difference  is  even  more  strikingly  presented  with 
Mallory's  stain,  which  colors  the  connective  tissue  a  deep  blue,  while 
the  muscle  is  stained  red.  The  border  of  the  tumor  is  always  sharply 
circumscribed,  even  in  the  very  small  ones.  This  has  led  some  patholo- 
gists to  believe  that  they  originate  in  a  congenital  displacement  which 
never  has  been  in  organic  union  with  the  normal  tissue  about.  The 
frequent  presence  of  a  small  vessel  in  the  centre  of  these  small  tumors 
has  been  thought  by  some  to  indicate  that  the  vessel  walls  are  the  source 
of  the  tumor  formation. 

Fig.  is 


\'N^'= 


':SX^X 

X     &\-''- 

\-'^-^       ■■\ 

':      \^        -v-            ■      \ 

^-     -V"';        ■,  '    ■ 

^1'"^ 

■'      "^>      '-^^              ■' 

■  ''."' '    •  '~7   '    -' '.  !■ '    ~~ 

i.-\  '"  'X\ 

Myoma  of  the  uterus,  showing  muscle  bundles  cut  longitudinally  and  transversely. 

Growth. — The  disposition  of  myomas  is  to  grow  slowly  but  persist- 
ently, displacing  the  neighboring  tissue  but  not  invading  it.  The  rate 
of  growth,  however,  varies  considerably.  The  more  fibrous  variety 
may  become  stationary,  while  others  may  grow  with  considerable 
rapidity.  Very  rapidly  growing  types  are  sometimes  seen  and  metas- 
tases in  distant  organs  have  been  observed.  The  border-line  between 
these  and  the  much  more  frequent  myosarcoma  is  difficult  to  place. 
Spontaneous  limitation  of  growth  may  take  place  by  secondary  degen- 
eration. Frequently  growth  ceases  when  the  organ  in  which  they  lie 
undergoes  regressive  changes  (uterus),  but  even  after  such  changes 
renewed  growth  is  possible.  When  their  original  source  of  blood  supply 
is  jeopardized  they  may  form  attachments  to  convenient  organs  and 
thus   receive  a  new  supply  of  nutriment. 

Degeneration. — Because  of  their  precarious  blood  supply  they  are 
subject  to  the  various  degenerations  resulting  from  a  limitation  of 
nutriment.  The  most  frequent  is  a  myxoid  degeneration  (Fig.  i6). 
Many   tumors   show  this  in   some   region.      Hyaline   degeneration   may 


MIM.l)   I    IKII/niiS  71 

result.  Fatty  defeneration  is  rarcl\  ohsirvid.  An\  ot  these  t\pes  mav 
liquefy  and  j^ivc  rise  to  c\st  toiinarions  or  ni:i\  form  cavities  info  wliiili 
lunioriha<ie  iiia\   occui. 

Mixed  Varieties.  I'lu-  pnscncc-  of  hhioiis  tissue  is  so  constant  that 
the  prtfix  "Hino"  stniis  as  much  out  of  place  as  in  the  designation 
of  carcinoma.  Ihe  hhrous  tissue-  often  predominates  in  (piantity,  hut 
the  muscular  element  is  thi'  more  important  hecause  it  underj!;oes  the 
initial  i^rowth.  Myolipomas  are  usuall\  degenerative,  tat  ver\-  rarel\- 
taking  an  active  part. 

Fig.  1 6 


a- 


-A-.-Z) 


Myoma  of  the  uterus,  showing  myxoid  degeneration:    a,  myxomatous  tissue; 

b,  mvoma  cells. 

But  in  a  few  instances  proliferation  of  fat  cells  in  m\omas  have  been 
recorded.^  In  these  cases  fat  cells  occur  in  groups  with  a  supporting 
framework  of  muscle  cells.  Macroscopically,  the  fatty  areas  show  as 
yellowish   or  whitish   areas,  which  when  scraped  with  a  knife  yield  fat 

droplets. - 

The  admixture  or  coincidental  occurrence  with  sarcoma  furnishes 
by  far  the  more  important  combination.  Some  pathologists  main- 
tain that  sarcomas  growing  in  myomas  must  spring  from  the  accom- 
panying fibrous  tissue.  Careful  tinctorial  studies  at  the  lines  of  transi- 
tion seem  to  leave  but  little  doubt  not  only  that  non-striated  muscle 
cells  may  become  the  starting  point  of  sarcoma,  but  that  such  a  trans- 
formation of  muscle  cells  may  take  place  by  contiguity  with  sarcomatous 

^  For  literature,  see  Benenati.  Virchow's  Arch.  f.  path.  .Anat..  1903,  clxxi,  418. 
~  Kno.x,  Lipomyoma  of  the  Uterus.  Johns  Hopkins  Hosp.  Bulletin.  1901,  xii,  318. 


72  MYOMAS 

tissue.  This  view  is  substantiated  by  the  experience  that  tumors  may 
develop  as  typical  myomas,  then  take  on  rapid  growth,  and  become 
mahgnant. 

Differentiation. — The  use  of  differential  stains  makes  the  recognition 
of  myomas  eas}^  In  the  absence  of  these  the  close  parallel  arrange- 
ment of  the  bundles  with  the  smaller  vessels  and  the  size  and  uniformity 
of  the  nuclei  are  quite  characteristic.  In  the  rapidly  growing  myomas 
a  differentiation  from  sarcoma  may  be  difficult.  The  varying  sizes  and 
shapes  of  the  nuclei  and  the  disregard  of  any  regular  arrangement  of  the 
fiber  bundles  relative  to  the  axis  of  the  small  vessels  m  the  sarcomas 
furnish  the  chief  differential  signs. 

Treatment. — Their  removal  is  indicated  because  of  their  disposition 
to  grow  and  cause  compression  on  neighboring  parts  and  to  undergo 
malignant  degeneration. 

Rhabdomyoma. — It  is  improbable  that  adult  muscle  cells  are  capable 
of  tumor  formation,  and  it  is  even  questionable  if  striated  muscle  cells 
in  embryonal  misplacements  take  an  active  part  in  the  tumor  forma- 
tion. The  belief  that  such  tumors  are  always  due  to  developmental 
anomalies  depends  upon  the  fact  that  they  occur  in  sites  of  embryonal 
tumors,  the  region  of  the  kidney  having  been  the  site  of  the  majority 
of  them. 

Microscopic  Appearance. — The  individual  fibers  are  usually  much 
smaller  than  a  normal  fiber  and  the  striations  are  less  marked.  Often 
one  end  is  clubbed.  The  nucleus  may  be  in  the  clubbed  extremity,  but 
usually  the  entire  length  of  the  cell  is  studded  with  relatively  large 
nuclei. 

Growth. — The  development  of  these  tumors  is  usually  dependent 
upon  the  associated  tissue.  In  general,  they  behave  like  the  mixed 
tumors,  remaining  dormant  for  a  variable  length  of  time,  but  ultimately 
undergoing  malignant  development. 


C  II  A  V  I    K  R     \    I 
MUROM  AS 

General  Conception,  lihiomas  are  tumors  which  have  their  proto- 
t\  pc  m  normal  hbrous  connective  tissue.  I'hey  develop  from  Hhro- 
blasts  which  tend  to  produce  mature  fibrous  tissue,  as  in  healing  wounds 
and  in  the  granulomas,  but  they  differ  from  these  formations  in  that 
they  serve  no  useful  purpose.  The\'  occur  in  the  habitat  of  normal 
fibrous  tissue;  most  frecjuentl)-  in  the  subcutaneous  reticular  tissue, 
in  the  septa  of  the  muscles,  and  about  the  fibrous  sheaths  of  nerves. 
The  kidneys,  uterus,  and  ovaries  are  the  parenchymatous  organs  most 
frequently  affected. 

Classification. — Fibromas  may  be  divided  into  classes  according  to 
their  structure;  as  simple,  composed  of  cells  and  fibers;  mixed,  which 
are  simple  fibromas  plus  various  other  tissues,  such  as  mucoid,  muscular; 
and  finally,  a  group  of  special  varieties  ma^'  be  distinguished. 

Simple  Fibromas. — Fibromas  vary  in  consistency  from  bony  hardness 
to  semifluctuating  softness.  ~Two  groups,  having  in  general  different 
plans  of  structure,  the  one  corresponding  to  dense  fibrous  tissue,  the 
other  to  loose  reticular  tissue,  may  be  distinguished. 

Hard  Fibromas. — These  are  usually  firm,  creak  under  the  knife, 
and  are  pearh'  white  in  color.  On  section  the\'  appear  to  be  made  up 
of  bundles  of  fibers  arranged  in  waves  and  whorls.  They  are  expansile 
tumors  and  affect  the  surrounding  tissue  only  by  displacing  it  (Fig. 
17).  Bloodvessels  often  course  through  the  centre  of  the  bundles, 
and  ma\',  when  the  circulation  is  disturbed,  give  rise  to  an  exudate 
among  the  fibers  which  renders  the  tumor  soft  and  semifiuctuating 
and  glistening  on  section. 

MicroscopicalK"  the  bundles  are  made  up  of  fibrillae,  among  which 
connective-tissue  cells  are  scattered  in  greater  or  less  numbers.  These 
cells  are  fusiform  with  long,  narrow,  intensely  staining  nuclei  (Fig. 
18).  In  the  denser  types  the  cells  are  comparatively  few,  while  in  the 
softer,  faster  growing  types  they  are  more  numerous  and  usually  have 
broader  nuclei  and  a  more  abundant  protoplasm  (Fig.  19).  In  fact, 
the  cellular  element  may  be  so  abundant  as  to  suggest  malignancy. 
The  cells  are  of  nearly  uniform  size  and  are  arranged  with  their  long 
axes  parallel  to  each  other;  they  are  usually  interspersed  with  fiber 
bundles   containing   few   cells.      In    the   edematous    t\pe    the   cells   are 


74 


FIBROMAS 
Fig.  17 


'JP- 


Small   fibroma   of  the  kidney,  showing  displaced   kidney   tissue. 


Fig.  18 


J 


(  J 


yy    /,' ' 


-"/,' 


'--/ 


.     ^  /'  ;    y 


/ '/  ' 


;  ;  tC/  "'  :^y'y. 


•V^ 


/ 


'    / 


/  / 


I      } 


y 


--.^y/-; 


r,V  '.,,- 


Hard  fibroma. 


Fig. 19 


ii.iRi)  r//iko.\t./s  7.") 

larjjer  and  more  spherical  and  the  hhers  are  pressed  aparr  h\   the  exudate 
and  stain  indetinitely'  (  Fi^.  20). 

1  he  sl()\vl\  jirowinji.  Hhronias  are  iisiiall\  p()()rl\  siipphed  with  Mood- 
vessels,  luit  I  hi  iapull\  iirowiiii;  r\  pe  is  often  ver\'  vascular.  The  vessels 
are  usuall\'  hned  h\  a  single  la\er  of  endothelial  cells,  hut  in  activel\- 
developinji  areas  these  cells  may  he  several  la\ers  deep,  and  ma\-  ^ive 
the  rumor  a  slight  resemhiance  to  an  endothelioma.  In  some  instances 
hhromas  possess  large  cavernous  vessels  resemhiing  angiomas,  and  it 
ma\'  simpl\-  he  a  matter  of  present  preference  whether  the  growth  shall 
he  called  an  angioma  with  ahundant  connective  tissue  or  a  vascular 
fibroma.  The  gross  aspect  of  the  tumor  gives  a  more  reliable  clue  to 
its  nature  than  a  microscopic  study,  particularly  if  hut  limited  areas 
of  the  tumor  are  examined. 


"1   ^ 


"■,v 


\/-j 


h 


'U> 


.■ .  '  f^. 


Edematous  fibroid  of  the  uterus. 

Secondary  Chaiiges. — -Myxoid  degeneration  is  the  most  frequent 
retrograde  change  in  these  fibromas.  It  occurs  in  the  older  parts  ot 
the  tumor  where  the  blood  supply  is  least  perfect.  Fatt\'  degenera- 
tion is  sometimes  seen,  often  associated  with  the  myxoid  degeneration. 
Liquefaction  in  such  degenerated  areas  ma\'  occur,  giving  rise  to  cysts, 
though  this  is  rare.  Hemorrhage  into  the  tumor  and  the  formation  ot 
cholesterin  crystals  have  been  noted.  Calcareous  infiltration  is  often 
associated  with  other  degenerations  as  an  end  result.  The  lime  salts  are 
deposited  among  the  fiber  bundles  so  as  to  form  spicules  which  otten 
resemble  bone.  True  bone  formation  has  been  noted,  but  evidently 
many  of  the  cases  reported  as  such  have  really  been  calcareous  infiltra- 
tion. 

^  For  the  finer  structure  of  fibromas,  see  Mallory,  A  Contribution  to  the  Classifica- 
tion of  Tumors,  Jour.  Med.  Research,  1905,  xiii,  113. 


76 


FIBROMAS 


Soft  Fibromas  (Fig.  21). — The  soft  fibromas  resemble  closest  the 
submucous  reticular  tissue  and  are  usually  found  just  beneath  the 
mucous  or  cutaneous  surfaces.  They  may  be  either  circumscribed  or 
diffuse.  Those  which  arise  from  the  deeper  tissues  are  usually  cir- 
cumscribed and  form  irregular  masses.  The  subcutaneous  variety  is 
inclined  to  be  diffuse,  so  much  so  that  in  many  cases  it  is  difficult  to 
distinguish  them  from  inflammatory  thickenings,  especially  since  the 
conditions  often  co-exist.  Both  types  are  frequently  edematous  because 
of  the  disturbance  of  circulation.  They  are  soft  and  semifluctuating 
on  palpation.  A  cut  section  is  white  or  pink  in  color,  and  usually 
glistening.  A  network  of  fibers  can  usually  be  made  out,  and  in  some 
areas  the  fibers  may  be  so  abundant  as  to  cause  resemblance  to  the 
hard  variety. 

Fig.  21 


i^/ 


'-e: 


#'-' 


Soft  fibroma  of  the  subcutaneous  tissue,  showing  loose  reticular  tissue,  round 
connective-tissue  cells,  and  bloodvessels. 


Microscopically  the  fibers  form  a  network  containing  connective- 
tissue  cells  within  its  meshes.  These  cells  are  round,  with  darkly  stain- 
ing nuclei  and  a  considerable  amount  of  protoplasm  (Fig.  5).  They 
are  most  abundant  about  bloodvessels.  Stellate  cells  are  frequently 
observed  as  well  as  large  cells,  with  opaque,  faintly  staining  nuclei,  with 
one  or  more  deeply  staining  nucleoli.  In  regions  of  inflammatory 
reaction  polynuclear  leukocytes  may  be  seen.  Bloodvessels  may  be 
present  in  great  abundance,  and  thin-walled  capillaries  are  seen  every- 
where coursing  through  the  loose  meshwork  of  fibers.  The  presence 
of  these  vessels  and  the  stellate  cells  frequently  lead  to  a  diagnosis  of 
myxoma.  A  chemical  test  will  obviate  this  error.  In  the  fibromas 
involving    the    skin    the    elastic    fibers    are    quite    uniformly   increased.^ 

^  Baldwin,  Vaughn  Anniversary  Contributions,  Wahr,  Ann  Arbor,  1903,  p.  495. 


spKc/./L  I  jki/rriKs  or  i  ihrumis  77 

Secondary  Chaugt's.-Vh*:^^:  an  limited  to  in\  xoniatous  and  fatty 
changes  and  cdcnia  and  an-  most  h((|iuiit I\  the  result  of  inflaniniatory 
processes.  So  otiiii  ;iic  intlaininatoi\  piocesses  assf)ciared  with  the 
orhei  ihmiui  at  loiis  that  Hu\  woiihl  stiiii  to  he  in  inaii\'  msfanees  the 
pi  imar\    (.'oniiihca  t  ion. 

Mixed  Varieties.  .\  tumorous  mt  lease  ot  hhi(;us  tissue  is  iieciuently 
associated  with  othtr  r\  pes  of  tissue.  These  tissues  mav  he  of  lower, 
hke,  or  hit^hei"  order. 

I  nless  the  hhrous  tissue  takes  an  active  part  in  the  tumor  forma- 
tion it  should  not  he  represented  in  the  name.  Fre(juentl\'  a  tumor 
IS  made  up  laii;el\  of  fihrous  tissue  without  conn  ihurin<;  an\  thm^  to 
the  essential  nature  of  the  tumor,  as  m  so-called  Hhrocarcinoma,  in 
which  the  connective  tissue  is  merely  the  supporting  framework;  nor 
should  a  compt)und  term  be  employed  when  the  associated  tissue  is 
the  product  of  a  degeneration,  as  in  my.xoid  degeneration  of  a  fibroma. 
There  is  in  general  a  disposition  to  employ  the  prefi.x  "fibro"  when- 
ever there  is  an  easil\'  perceptible  amount  of  fibrous  tissue,  irrespective 
of  its  histogenic  importance.  The  essential  nature  of  the  tumor  is 
often  obscured  because  of  such  fault}^  nomenclature. 

Some  of  the  more  common  mixed  fibrous  tissue  tumors  are: 

Myxofibrom.a.s. — Myxoid  tissue  is  usually  found  with  the  soft  type 
of  fibroma  in  the  deeper  tissues,  especially  of  the  nervous  system. 

LiPOFiBROMAS. — The  fibrous  element  of  these  tumors  is  generally 
of  the  hard  variet}'.  The\'  are  oftenest  situated  in  the  subcutaneous 
tissue  and  in  parenchymatous  organs.  Fibromas  growing  about  and 
enclosing  lobules  of  preexisting  fat  and  lipomas  containing  thick 
fibrous  septa  are  not  properl\'  included  in  this  variet\'.  True  fibro- 
lipomas  are  rare  and  of  little  importance. 

FiBROMYOMAS. — Non-striated  muscle  fibers  form  the  most  common 
combination  with  fibrous  tissue.  All  degrees  of  admixture  are  found. 
This  t\'pe  occurs  most  frequently  in  the  uterus,  and  is  discussed  under 
m^'omas. 

Adenofibromas. — These  tumors  are  usuall\'  found  in  the  mam- 
mar}'  gland.  The^'  are  hard  fibromas  which  have  included  in  their 
growth  relativeh'  normal  gland  acini.  The  tumors  in  which  the  glands 
are  active  participants  will  be  discussed  under  adenomas. 

Fibrosarcomas. — This  term  is  properl\'  reserved  tor  sarcomas  of 
low  degree  of  malignanc}-  in  which  the  fibers  nearl}-  reach  full  develop- 
ment. Often  some  regions  of  the  tumor  present  completeh'  developed 
fibrous  tissue. 

Special  Varieties. — There  are  a  number  of  new  formations  made  up  of 
fibrous  tissue  which  form  distinct  types,  and  are  best  described  as  varieties 
of  fibromas.     Manv  of  these  are  not  true  tumors,  but  since  they  appear 


78  FIBROMAS 

clinically  as  such  they  are  included  in  this  discussion.  This  is  partic- 
ularly necessary,  since  some  of  them  may  not  appear  as  tumors  under 
some  conditions,  but  do  appear  as  such  under  other  conditions,  e.  g., 
elephantiasis. 

Keloid  (Fig.  22). — By  keloid  is  meant  a  dense  fibrous  growth  which 
occurs  in  the  subcutaneous  tissue  usually  at  the  site  of  a  scar.  Two 
types  were  formerly  recognized — the  true,  in  which  no  previously  exist- 
ing scar  was  present,  and  the  false,  which  developed  from  a  scar.  It 
is  now  assumed  that  a  very  small  scar  may  be  the  point  of  origin  of  the 
true  variety  as  well,  and  therefore  both  types  are  genetically  the  same. 

Fig.  22 


Keloid,  showing  large   connective-tissue   fibers   and   nuclei   of  fibrous-tissue   cells. 

These  varieties  cannot  be  differentiated  pathologicall}'  or  clinically, 
whatever  may  be  the  etiological  factors.  They  ma}^  be  round,  lobu- 
lated,  or  irregular  in  outline,  projecting  a  centimeter  or  more  above 
the  surface.  When  they  grow  from  a  scar  the}'  usually  take  the  form 
of  the  scar  itself,  but  they  ma^'  extend  irregularly  into  the  surrounding 
tissue.  They  are  dense  to  the  touch  and  may  be  more  or  less  fixed  to 
the  underlying  structure,  particularly  if  they  go  out  from  scars  involv- 
ing the  deeper  tissues.  When  arising  spontaneously  or  from  slight 
injuries,  they  are  usually  movable  over  the  underlying  tissue.  They 
are  found  most  frequently  on  the  chest,  back,  face,  and  lobes  of  the 
ear.    The  negro  race  is  especially  predisposed. 

Histologicalh"    they    are    characterized    by    very    large    homogeneous 


E  I. Ill' 1 1. 1  \  ri.isis  79 

fibers  iiUtispt  Tstcl  with  tew  coniuttiNc-tissue  cells  li;i\  inu  mikiII  inttiiseU 
staining  luick-i  i  I"  ij;.  ii).  Iluii  liisrolojiN'  ^l\•l■s  no  cliu-  lo  rlic  cause 
of  tluii'  (Jisi^osition  to  recur. 

1' iiiiuciulv  ui  tin-  luahnti,  of  wouiujs  excessi\c-  scar  tissue  is  forimd 
and  masses  reseiiihlin^  keloids  may  he  produced.  liie)'  are  distin- 
jiuished  from  riie  lattir  hy  the  ^:reater  numher  of  cells  and  by  the  smaller 
fibers  (  I'i^.  23),  ami  h\  rheir  association  with  recently  healed  wounds 
ot  somr  ma<;mriidc,  |iai  riciilaily  burns.  I  hey  tend  to  iirroji;ressive 
chanj^es.      Sonuwhar    anal()<i;ous   to   keloids   are    the   so-called    desmoids. 

Fk;.  23 

^-^:'    ■■'■     ■■'-■         '.    '        '  <^-  ^'  '-^^.^  V,  "c^. 


.v 


»c.^ 


:■*- 


"'         "^ 

:.-.'.>n:5 

^% 

-_. 

^ 

-  "4 

■~1—- 

'^-^ 


Hypertrophied  scar,  showing  large  connective-tissue  ceils  and  fibrillae. 

These  are  made  up  of  more  or  less  cellular  tissue  with  large  fiber  bundles. 
This  term  is  properly'  applied  to  tumors  of  this  character  occurring  in 
the  abdominal  wall,  which  will  be  considered  in  the  discussion  of  the 
tumors  of  that  region. 

Elephantiasis. — Elephantiasis  is  a  diffuse  fibrosis  of  the  subcuta- 
neous connective  tissue,  and  to  a  less  degree  of  the  fibrous  tissue  of 
the  deeper  lying  structures,  the  intermuscular  septa,  perivascular 
sheaths,  etc.  Two  types  have  generally  been  distinguished,  the  con- 
genital and  the  acc]uired. 

Congenital. — Usualh'  onh'  the  anlage  of  the  growth  is  present  at 
birth,  but  soon  afterward  it  begins  to  develop  rapidly.  In  acephalic 
monsters  it  is  sometimes  well  developed  at  birth,  and  it  may  e.xtend 
over  the  entire  body.  This  variety  has  been  proved  in  recent  }-ears 
to  be  formed   from    the   nerve   sheaths   (elephantiasis   neuromatosa,   v. 


80  FIBROMAS 

Recklinghausen's  disease^.  It  is,  in  other  words,  a  diffuse  fibromatosis 
of  the  nerve  sheaths.  Later  the  process  is  beheved  to  extend  to  other 
fibrous  tissue,  especially  that  of  the  blood  and  lymph  vessels.  A  further 
indication  of  intimate  connection  with  the  nerves  is  the  fact  that 
elephantiasis  is  frequently  combined  with  true  tumors  in  other  parts 
of  the  nerves.  Pachydermatocele,  a  similar  process,  has  likewise  been 
proved  by  Herczel^  to  go  out  from  nerve  sheaths. 

Acquired. — This  type  occurs  endemically  in  the  tropics  and  spor- 
adically in  other  climates.  In  the  tropical  form  the  whole  limb  is 
affected,  owing  to  occlusion  of  the  main  lymph  trunk  by  the  Filaria 
sanguinis  hominis.  It  is  very  rare  in  temperate  regions,  and  interest 
in  it  is  scientific  rather  than  clinical.  In  this  country  a  localized  form 
in  the  genital  region  not  uncommonly  follows  the  operative  removal 
of  the  inguinal  glands  or  their  destruction  by  inflammation.  It  may 
also  be  produced  hy  diffuse  inflammation  of  the  cellular  tissue.     Often 

Fig.  24 


Elephantiasis,  showing  fiber  bundles  and  cells. 

the  localized  form  in  other  parts,  such  as  the  scalp  and  hips,  has  no 
obvious  cause.  It  is  characterized  by  soft  flabby  masses  which  pro- 
ject or  hang  from  the  point  of  origin;  often  the  epidermis  is  irritated 
and  a  rough  encrusted  or  weeping  surface  results.  Pathologically  the 
earliest  change  is  in  the  skin,  the  corium  first  becoming  thickened, 
and  then  the  papillae  becoming  elongated,  hypertrophied,  and  branched. 
The  epidermis  is  thickened  and  the  interpapillary  processes  proliferate. 
The  principal  change  is  in  the  subcutaneous  connective  tissue,  which 

^  Von  Recklinghausen,  Ueber  die  multiplen  Fibrome  der  Haut  und  ihre  Beziehung 
zu  den  multiplen  Neuromen,  Berlin,  1882. 

^  Ueber  Fibrome  und  Sarkome  der  peripheren  Nerven,  Beitr.  z.  path.  Anat.  u.  z. 
allg.  Path.,  1890,  viii,  38. 


/)i.i(..\osjs  or  iiHko.M.is  si 

becomes  nuieli  thitkeiutl,  the  filnis  Inconiin^  laijie  aiul,  unless  etleina- 
tous,  dense.  Round  cells  max  In-  diHused  over  lar^e  areas  or  collecred 
into  groups  (Fig.  24).  I  lie  connecriN  e-tissue  spaces  contain  a  in\  xoid 
tissue  which  renders  tin  mass  firm  ami  elastic  to  the  t(juch.  1  he  \eins 
are  often  the  seat  of  noilular  hhrous  thickening  or  saccular  dilatation. 
The  arteries  show  marked  thickenmji  of  the  walls  ami,  in  spite  ot  this, 
an  iiu  iiase  m  calilni.  I  lu  l\  nipli  \essels  and  spaces  are  maikiilU 
thiated,  and  their  endothelial  lining  cells  often  proliferate,  prohahh  on 
account  ot  a  chemical  change  in  the  composition  of  the  l\mph. 

Xanthoma. —  Ihese  are  peculiar  yellow  or  brown  tumors  which  occur 
in  the  skill.  .More  than  three-fourths  of  them  are  on  the  e\  elids.  rhe\' 
are  treiiuenrly  multiple,  and  are  then  arranged  along  the  C(jurse  of  a 
cutaneous  nerve.  I  hey  form  flat  nodules  or  patches,  but  sometimes 
may  be  large  enough  to  become  pol\'poid.  While  the\'  seem  alwa\'s 
to  begin  in  the  cutis,  they  extend  deeper  into  the  connective  tissue 
and  even  into  the  muscle  and  periosteum.  They  appear  frequenth- 
where  the  skin  is  subjected  to  pressure  or  over  bony  prominences. 
In  some  congenital  cases  the}'  are  located  more  deepl\'  under  the  skin. 
They  are  composed  of  fibrocellular  nests  which  extend  into  the  Kmph 
spaces.  There  is  always  a  la^er  of  cutis  between  the  tumor  and  the  epi- 
dermis. The  color  of  the  tumor  is  due  to  a  \ellow  pigment  in  the  cells. 
The  chief  characteristic  of  the  tumor  is  the  occurrence  of  large  cells 
which  look  like  fat  cells,  and  which  led  \  irchow  to  call  these  tumors 
fibrolipomas.  Some  of  them  have  giant  cells  resembling  those  of  sarcoma, 
and  are  frequenth'  associated  with  icterus  and  other  hepatic  disturb- 
ances. 

Diagnosis. — Macroscopic. — The  hard  tibromas  are  well-defined,  en- 
capsulated tumors,  dense  to  the  touch  and  on  section.  The}'  are  pearl\' 
white  in  color  and  show  wavy  bands  and  whorls.  In  the  ver\'  vascular 
t\pes  the  lumen  of  the  vessels  may  sometimes  be  detected  b\'  the  naked 
eye.  The  softer  varieties  are  less  sharpl\'  circumscribed  except  in  cases 
where  the\'  are  pedunculated.  Lsuall}'  on  section  these  show  bands 
of  fibers  in  a  glistening  homogeneous  matrix.  Their  slow  growth  and 
the  features  detailed  above  make  the  diagnosis  eas}'. 

Microscopic. —  In  man\'  instances  the  microscopic  diagnosis  is  more 
difficult  than  the  clinical.  The  sparseness  ot  the  nuclei,  their  uniform 
size,  oblong  shape,  and  arrangement  parallel  to  the  fibers  ma\'  be 
regarded  as  the  most  important  signs  of  fibroma  so  far  as  the  nucleus 
is  concerned.  The  parallel  arrangement  of  the  fiber  bundles  and  the 
bloodvessels  is  evidence  of  a  benign  tumor.  However,  in  some  fibromas 
the  nuclei  are  less  regular  in  form,  particularl}'  if  there  has  been  some 
secondar\'  change,  and  the  fiber  bundles  ma\  var\'  from  the  normal 
arrangement.  In  such  cases  the  diagnosis  depends  upon  the  histor\  ot 
6 


82  FIBROMAS 

the  growth  and  upon  special  considerations  which  will  be  taken  up  in 
connection  with  particular  regions. 

Prognosis. — The  prognosis  in  all  varieties  of  fibromas  as  regards 
Hfe  is  uniformly  good.  There  is  no  disposition  to  form  metastases, 
and  when  simple  fibroids  are  once  removed  they  do  not  tend  to  recur. 
In  some  of  the  soft  types  which  extend  diffusely  into  the  tissue  new 
tumors  may  recur  in  the  site  of  operation.  With  keloids  local  recur- 
rence is  the  rule. 

Treatment. — Fibroids  when  the}^  cause  annoyance  by  their  size 
should  be  removed.  The  hard  type  may  be  readily  shelled  out  by 
splitting  the  skin.  In  the  soft  type,  particularly  when  pedunculated, 
an  elliptical  incision  about  the  base  may  be  made  in  order  to  remove 
the  redundant  skin.  The  keloids  tend  to  return  when  removed,  and 
had  better  be  left  unmolested  unless  located  on  an  exposed  surface, 
when  excision  may  be  practised  under  a  guarded  prognosis.  Elephan- 
tiasis when  localized  may  be  excised.  When  an  entire  limb  is  involved, 
ligation  of  the  chief  arterial  supply  may  be  undertaken.  Recently, 
reports  have  been  made  of  keloids  treated  by  the  A;-rays  by  Pusey,^ 
Morton,-  and  others. 

^  Jour.  Amer.  Med.  Assoc,  1902,  xxxviii,  916. 
2  Med.  Record,  New  York,  1903,  Ixiv,  124. 


C  II  A  1'   r  K  k     \    I   I 
GLIOMAS 

Conception  and  Definition,  (iliomws  aw  tuiiiois  toinu-d  tioin  tlic 
supportiNf  tranuwoik.  of  the  central  lurxous  system,  and  are  found 
not  onh'  in  the  brain  and  spuial  cord,  hut  also  in  the  e\e.  An  exact 
pathological  conception  of  glioma  is  difficult;  the  structure  of  the  glia 
cells  is  not  sufficiently-  understood.  Ihere  is  still  a  question  as  to  the 
relation  of  the  fibrillar  network  to  the  cells.  W'eigert  believed  that 
b\'  the  use  of  his  stain  he  had  demonstrated  their  independence  of  the 
cell.  Others'  regard  the  fibrilhe  as  prolongations  of  the  cell  proto- 
plasm, and  therefore  as  a  part  of  it.  Unlike  other  sustentacular  tissue, 
glia  cells  are  derived  from  the  epiblast.  Gliomas  are  distinctive  enough 
in  their  clinical  course  to  warrant  a  separate  consideration.  They  are 
the  most  frequent  true  tumor  involving  the  central  nervous  system. 
The\'  occur  most  frequentl)'  in  earl\-  life,  usually  in  children. 

Macroscopic  Appearance. — Gliomas  present  the  physical  characters 
of  the  sustentacular  tissue  of  the  central  nervous  system  from  which 
they  spring.  They  are  little  different  in  color  from  the  gray  substance 
and  are  gra^'er  than  the  white  substance.  Most  cases  of  so-called  brain 
hypertrophy  are  due  to  such  tumors  (Oppenheim).  Frequently,  they 
are  differentiated  from  the  surrounding  tissue  by  their  greater  vas- 
cularity, the  individual  vessels  being  often  distinguishable.  The}'  are 
usually  infiltrative  in  growth  and  have  no  sharply  defined  border.  They 
can  usually  be  distinguished  from  the  surrounding  brain  substance 
b\'  their  greater  softness,  which  is  sometimes  increased  by  secondarx' 
changes.  In  some  cases,  however,  and  this  is  particularly  true  of  the 
smaller  circumscribed  tumors  near  the  corte.x  and  in  the  ventricles, 
the\-  are  denser  than  the  surrounding  tissue. 

Microscopic  Appearance. — Normal  glia  cells  have  round,  deep-stain- 
ing nuclei  of  uniform  size  and  very  little  protoplasm.  In  gliomas  the 
cells  vary  in  structure;  they  approach  the  normal  at  the  peripher\-  of 
slowly  growing  tumors,  and  deviate  most  toward  the  centre  of  the 
rapidly  growing  tumors.  According  to  the  degree  of  variation  the 
cytoplasm    is    increased,  and    its    nuclei    become    larger   and    ovoid;    in 

1  Taylor,  Jour.  Exper.  Med.,  1897,  ii,  611;  Golgi,  Glioma  des  Cehirns,  Fischer,  Jena, 
1884;  V.  Lenhossek,  Der  feinere  Bau  des  Nervens^stems,  Fischer,  Berlin,  1895. 


84 


GLIOMAS 
Fig.  25 


c> 


M"^ 


i^\ 


&     /y' 


Glioma  of  cord,  showing  glia  cells  with  processes  and  connective  tissue  about  a 

bloodvessel. 


Fig.  26 


^M'H 


W-^i% 


. "^  fcf'      ?\.' :       . <%. 


f  d 


^-f. 


<B 


^■^ 


:-^ 


w 


id;)    .    ^. 


^^ 


@      ;    -f 


r  §^\.^#^^i  ■  f/^^,^'>^'^,^ 


f  ;,  :# 


© 


^ 


\(^ 


(B 


Glioma  of  brain,  showing  glia  cells  without  processes,  and  connective  tissue. 


modi:  (>i  (.Ron  rii  or  (./.io.m.is  s5 

rlu-  i;i|Mill\  ^louinii  i:,ln»iu;is  wiili  ;i  hii;li  di-^iii-  ol  \  ;ii  i;i t loii  tlu-  fll)rils 
becoiiu'  it-l:iti\  cl\  lew.  In  sp(rinuns  wliuli  ;ii(  teased  or  staiiucl  hy 
special  nurlKuls,  tin-  s|Mclii-likt  loiin  ol  tlu  <;li;t  nils  l^ccoincs  apparent 
(Fiji;.  25).  Ill  tlu-  tastii  i:i()\\m<;  t\  jus  tlu-  cills  aic  less  perfectl\'  formed 
ami  tlu  sullati-  aiul  spiiullc-shapt-d  \aiic-tus  pii-doiiiinare  (Hfi;.  26). 
1  lu   nils  iiKi\    In-  so  hum-  as  to  ii-scnd^K-  ^aii^hon  tx-ils. 

Differentiation  from  Sarcoma.  ilu-  naiiu-  fiiiosarcoiiia  has  Ixcn 
apjdu-d  to  lapulh  ^ row  1111;  tiiinois  ot  tlu-st-  lai^i-i  fells.  Ilu-  tiansi- 
tion  ot  a  ulioiiia  iiUo  a  sarcoma  is  unlikely,  for  ^lia  cells  have  been  .shown 
to  be  of  cpiblastic  orij^in.  Ilu-  chitf  itscniblaiui  to  sarcoma  is  in  rhe 
relation  of  the  cells  to  the  vessel  \salls;  rlu-  iniitation  is  \ei\  close-,  aiiel 
h\  histological  nuans  often  inipossihk-  to  eletect.  Mallor\'  is  contidenr 
that  differentiation  is  possible  b\'  means  of  his  technujue,  but  untortu- 
nateh'  material  Hxed  in  Zenker's  Huiel  only  permits  ot  such  stuel\  ,  a 
fixative  not  often  used  in  the  material  presented  tor  examination. 
Borst  has  sought  to  escape  this  difficulty  by  dividing  such  tumors  into 
two  classes:  (i)  The  verv  cellular  gliomas  he  calls  glioma  sarcoma- 
toides,  indicating  thereby  only  a  rapidly  growing  glioma;  (2)  the  glio- 
sarcoma,  in  which  both  kinds  of  tumor  are  growing  side  b\-  side.  Against 
this  classification  one  may  say  that  the  name  of  the  first  type  is  mis- 
leading and  that  the  second  type  has  not  been  observed.  The  resem- 
blance between  glioma  and  sarcoma  is  increased  by  the  presence  of 
intercellular  fibrils  in  both;'  and  to  establish  the  existence  of  glia  cells 
the  fibrils  must  be  shown  to  be  connected  with  the  c^-toplasm.  But  in 
rapidl\-  growing  tumors  man}'  glia  cells  are  free  from  processes;  the 
presence  of  small,  round  or  oval,  deeply  staining  nuclei  with  a  small 
amount  of  protoplasm,  so  suggestive  of  sarcoma,  renders  the  problem 
ver)'  difficult.  In  obscure  cases  other  points  ma\-  aid  in  diagnosis: 
The  presence  of  giant  cells,  degenerated  nerve  fibers,  and  corpora 
am\lacea  (Stroebe)  speaks  for  glioma;  in  glioma,  cells  are  not  arranged 
so  definitely'  about  the  vessels  as  in  sarcoma;  sarcomas  devele)p  from 
the  meninges  and  the  vessels  of  the  brain  only. 

Mode  of  Growth. — Gliomas  are  essentially  inhlrrative  in  growth, 
though  expansile  growth  may  occur  rarely  in  the  smaller  tumors,  which 
are  then  quite  sharply  defined  from  the  surrounding  tissue.  It  is  par- 
ticularly noteworthy  that  these  tumors  do  not  grow  beyond  the  border 
of  the  neural  tissue  in  which  they  develop.  Ihe  spaces  may  be  mhl- 
trated,  but  the  surrounding  membranes  are  never  penetrated  and 
destroyed.  Metastasis  does  not  occur  in  primary  glioma  of  the  brain, 
but  it  has  been  observed  in  gliomas  arising  from  developmental  di.s- 
placements   (Mallory)   and   from   the   retina.      Secondar\-   gnnvths   from 

'  Stroebe,  Centralbl.  f.  path.  .-Xnar..  181)4,  v,  855;  1806,  vii,  643. 


86  GLIOMAS 

the  retina  have  been  found  in  the  brain,  the  meninges,  and  the  spinal 
cord  (Arnold,  v.  Recklinghausen).  Although  gliomas  lack  many  of 
the  biological  characters  which  ordinarily  belong  to  malignant  tumors, 
they  are  of  grave  danger  to  the  life  of  the  patient  because  of  their  posi- 
tion. Some  of  the  very  small  ones,  particularly  those  growing  in  the 
lateral  ventricles,  are  innocuous;  and  a  number  in  the  cortex  have  grown 
so  slowl}^  as  to  appear  only  at  postmortem  exammation.  Ordinarily, 
however,  from  their  size  and  location  they  produce  compression  and 
destroy  the  function  of  the  organ  in  which  the}^  lie. 

Secondary  Changes. — Edema  and  myxoid  changes  sometimes  occur. 
The  former  is  more  often  seen  at  postmortem  than  at  operation,  and, 
indeed,  it  seems  possible  that  edema  is  a  terminal  manifestation  and  not 
a  factor  of  importance  in  the  life  history  of  the  tumor.  Myxomatous 
changes  are  most  likely  to  occur  in  those  types  in  which  the  fibers 
predominate.  The  term  gliomyxoma  has  been  applied  to  these  tumors, 
but  the  myxoid  element  is  probably  always  due  to  secondary  changes. 

Hemorrhage  is  the  most  important  accident  to  which  gliomas  are 
liable;  this  is  easily  understood  when  the  number  and  histology  of  the 
vessels  are  kept  in  mind.  Hemorrhages  which  cause  death  may  be 
so  extensive  as  entirely  to  obscure  the  tumor,  and  it  may  remain  un- 
detected, unless  a  microscopic  examination  of  the  region  of  the  hemor- 
rhage is  made.  The  occurrence  of  hemorrhage  into  the  brain  substance 
remote  from  parts  ordinarily  subject  to  apoplectic  accidents  should 
alw^ays  suggest  the  possibility  of  ghoma  and  lead  to  a  careful  micro- 
scopic investigation.  After  hemorrhage  the  blood  may  be  absorbed 
and  leave  cysts  filled  with  a  straw-colored  fluid,  the  origin  of  which 
is  indicated  by  the  presence  of  cholesterin  crystals.  Necrosis  and 
softening  of  the  tumor  area  sometimes  takes  place,  with  subsequent 
cyst  formation  and  death  of  the  patient. 

Gliomas  of  the  Cord. — Gliomas  of  the  cord  show  two  tendencies 
which  require  mention:  (i)  They  tend  to  infiltrate  the  cord  and  form 
solid  tumors  which  reach  for  considerable  distances;  (2)  these  long 
growths  tend  to  cavit}^  formation  and  resemble  very  closely  the  process 
called  syringomyelia.  In  the  cavities  thus  formed  ependyma  cells  are 
frequently,  found.  Oppenheim  does  not  believe  that  this  condition 
should  be  considered  with  gliomas. 

Gliomas  of  the  Retina. ^ — Rapidly  growing  tumors  of  the  retina  are 
observed  particularly  in  children,  and  are  regarded  as  gliomatous  in 
character.  They  are  soft  yellowish  or  grayish  tumors  which  develop 
in  the  interior  of  the  ej'e,  perforate  the  sclera,  and  invade  the  orbit. 

1  Emanuel,  Vircliow's  Arch.  f.  path.  Anat.,  1900,  clxi,  339;  Wintersteiner,  Das  Neuro- 
epitheHoma  retinae,  Leipzig,  1897. 


A/./  koCI.IOM  I  s~ 

1  lu\  tiiciiunt  1\  iii\;uli-  ilu-  M()()(l\  essils  aiul  itacli  ciisraiu  ()r;;ans  in 
this  iiianiui.  I  his  nuans  ot  chssiniinarioii,  tont-rhir  with  their  vci\' 
rapid  growth,  oaiisis  thtni  m  this  sitiiation  to  iiscmhic-  sarcomas  even 
more  than  those  aHeetmj;  the-  hiam.  I  he  small  size  ot  the  cells  and 
their  perivasculai  aiiangement  sometimes  makes  a  distinction  impos- 
sible. Iheir  nature  is  su^^ested  h\-  the  resemblance  to  the  retinal 
cells,  but  a  cknionstration  of  ^lia  Hbers  is  necessar\'  lor  a  j-xjsitive 
identification. 

Neuroglioma.  -Some  writers'  believe  that  neural  and  ^lia  tissue 
ma\  develop  simultaneously.  Ganglion  cells,  however,  probably  do 
not  develop,  and  those  cells  which  resemble  or  represent  them  are 
probably  embryonal  cells. 

Treatment.  Diffuse  gliomas  are  inoperable.  When  encapsulated 
they  can  be  shelled  out. 

Thomas  and  Hamilton,  Jour.  Exper.  Med.,  1897,  ii,  635. 


CHAPTER    VIII 
NEUROMAS 

Conception. — Neuromas  are  rare  tumors  derived  from  the  essential 
elements  of  the  nervous  system.  Any  of  the  various  nerve  elements 
may  at  times  be  the  seat  of  tumor  formation.  Much  confusion  has 
arisen  from  failure  to  distinguish  between  those  tumors  dependent 
upon  an  actual  increase  of  nerve  elements  and  those  in  which  the  nerve 
elements  are  purel}^  an  inclusion.  Chief  of  these  spurious  tumors  are 
the  fibromas  arising  from  the  fibrous  tissue  in  and  about  the  nerve 
sheaths.  Strictl}^  speaking,  such  tumors  should  be  discussed  with 
fibromas;  but  because  the  exact  differentiation  is  frequently  the  task  of 
the  laboratory  it  seems  best,  on  practical  grounds,  to  discuss  them  in 
this  connection  under  the  general  head  of  pseudoneuromas,  expressing 
thereby  their  association  and  topography  rather  than  their  histological 
structure. 

True  Neuromas. — In  this  group  are  included  those  tumors  in  the 
development  of  which  nerve  tissue  itself  takes  an  active  part.  Each 
element  of  the  nervous  system  may  form  tumors,  so  that  it  is  neces- 
sary to  recognize  ganglion-cell  neuromas  and  neuromas  derived  from  the 
nerve  fibers.  The  latter  are  again  divided  into  the  myelinic  neuromas 
derived  from  the  medullated  nerve  fibers,  and  the  amyelinic  neuromas 
derived  from  the  non-medullated  nerve  fibers.  Some  pathologists^ 
question  if  tumors  made  up  of  nerve  fibers  alone  ever  occur,  but  it 
seems  certain  that  such  true  neuromas  do  occur,  though  they  are  very 
rare.  Knauss^  has  recently  attempted  to  include  many  tumors  generally 
classed  as  pseudoneuromas,  but  his  opinions  have  not  received  general 
acceptance.  Neuromas  are  found  in  the  central  and  peripheral  nervous 
systems.  In  the  central  nervous  system  they  occur  most  frequently 
near  the  lateral  ventricles.  It  is  believed  that  they  are  dependent 
upon  developmental  errors,  though  it  is  difficult  to  distinguish  between 
origin  from  developmental  errors  and  from  masses  of  misplaced  tissue. 

Better  defined  are  the  neuromas  of  the  peripheral  nerves,  particularly 
of  the  sympathetic  system.^  Here  the  ganglion  cells  are  particularly 
numerous   and   are  often   of  large  size,  and  may  contain   many  nuclei. 

^  Ribbert,  Geschwiilstlehre,  Cohen,  Bonn,  1904,  p.  320. 

2  Zur  Kenntniss  der  achten  Neurome,  Virchow's   Arch.  f.  path.  Anat.,  1898,  cliii,  29. 

^  Schmidt,  Virchow's  Arch.  f.  path.  Anat.,  1899,  civ,  557. 


psi:ri)OM:rR(j.\i  IS  ^\) 

Neiironuis  art-  bt-m^ii  tiiniots,  luit  a  tVw  casts  have  been  reported 
in  which  iiK-rasrasis  occunecl.  1  hesc  arc  hchc\c(l  to  have  been  formed 
from  undcxclopctl  'iaii'ilioii  cells. 

Borst  has  pointed  out  that  the  cnor  of  mistaking  (jther  conditions 
for  true  neuromas  depends  upon  two  causes:  (i)  Ihe  nerve  cells  ma}' 
appear  as  inclusions  in  other  tumors,  for  example,  in  fibromas,  gliomas, 
or  sarcomas,  and  thus  play  only  a  passive  role.  This  error  may  be 
avoided  by  remembering  the  topographical  relationship  of  the  tumor 
in  question.  Ihus  if  a  sarcoma  is  developing  into  a  region  normally 
occupied  by  nerve  tissue,  a  discovery  of  nerve  fibers  should  cause  no 
confusion.  Confusion  is  particularly  likely  to  occur  in  tumors  develop- 
ing in  teratomas  where  no  normal  location  for  nerve  tissue  exists  and 
where  the  structure  deviates  from  the  normal.  (2)  Developmental  dis- 
placements without  any  newgrowth  of  tissue  may  be  mistaken  for  tumors. 
Unless  such  displacements  show  an  active  independent  development,  they 
should  not  be  regarded  as  tumors.  Artificial  displacements  of  nerve 
tissue  during  operations  and  autopsies  have  caused  confusion. 

Pseudoneuromas  'fibromas  of  the  Nerve  Sheaths,  Multiple  Neuro- 
mas).— These  tumors  are  usually  derived  from  the  endoneurium  and 
perineurium,  less  often  from  the  epineunum,  and  may  vary  from  a 
barely  discernible  size  to  the  size  of  an  orange.  1  hey  are  usually  spindle- 
shaped,  but  are  sometimes  globular  or  irregular  and  are  often  bilater- 
alh"  symmetrical.  This  symmetry,  together  with  their  very  early  or 
even  congenital  appearance,  suggests  a  developmental  origin.  These 
tumors  may  occur  in  great  numbers  distributed  over  the  entire  body. 
Prudden^  describes  a  case  in  which  there  were  eleven  hundred  and  eighty 
distinct  tumors.  Their  hereditary  occurrence  has  been  noted.  They 
may  involve  either  the  sympathetic  or  cerebrospinal  nerves  and  ganglia, 
both  spinal  and  sympathetic  being  not  rarely  involved;  when  they 
occur  in  the  ganglia,  ganglion  cells  are,  of  course,  present.  Askanazy- 
has  studied  these  tumors  in  the  gastro-intestinal  tract,  where  they  were 
located  in  Auerbach's  plexus  at  the  mesenteric  junction.  Their  inde- 
pendence of  nerve  fibers  is  attested  by  the  absence  of  disturbance  in 
the  conductivity-  of  the  nerve  even  in  extensive  tumors.  This  is  easily 
explained  anatomically  by  the  fact  that  the  nerve  fibers  are  pushed 
aside  by  the  growth  of  fibrous  tissue  and  onh-  late  or  not  at  all,  do 
the  fibers  exhibit  evidence  of  degeneration.  When  this  does  occur, 
pressure  is  most  likel\-  to  be  the  cause.  The  myelin  sheaths  may 
disappear,  but  the  axis  cylinders  remain  intact. 

Types. — The  clinical  significance  of  some  of  the  types  has  led  to 
various  subdivisions.    The  following  ma\   be  distinguished: 

'  Amer.  Jour.  Med.  Sci.,  1880,  l.xxx,  136.  -  Festschr.  f.  Neumann,  vol.  ii. 


90 


NEUROMAS 


Plexiform  Neuromas  TFig.  27)  Rankenneurom,  Bruns). — These  are 
characterized  by  a  more  or  less  diffuse  thickening  of  the  nerve  sheaths 
of  a  region  interrupted  by  locaHzed  thickenings  or  nodes.  In  addition 
to  the  increase  in  thickness  of  the  nerve  sheath  it  is  hkewise  increased 
in  length  beyond  the  requirements  of  the  region,  and  since  these  tumors 
have  a  predilection  for  the  head  and  neck  they  have  been  compared 
to  the  cirsoid  aneurysms.  They  are  often  accompanied  by  an  elephan- 
tiatic  thickening  of  the  fibrous  tissue.  The  fact  that  the  nerve,  as  a 
whole,  IS  both  thickened  and  lengthened  has  led  some  authors  TZiegler, 
Birch-Hirschfeld,  Klebs)  to  believe  that  the  nerve  elements  take  an 
active  part  m  the  process.  Ziegler  believes  this  fact  is  likewise  indicated 
b}^  the  presence  of  an  excessive  number  of  nerve  fibers.  Borst  believes 
that  connective-tissue  fibrils  may  be  mistaken  on  section  for  nerve 
fibers,  a  mistake  which,  indeed,  might  easil}^  happen.  No  attempt  has 
been  made  to  compare  numerically  nerve  trunks  in  normal  regions  with 
areas  involved  in  such  tumors.  The  lengthening  may  be  onl}"  inci- 
dental, the  nerve  fibers  being  merely  stretched  by  the  fibrous-tissue 
growth. 

Fig.  27 


Plexiform  neuroma.      fPrudden.) 


Traumatic  (Amputation)  Neuromas  (Fig.  28). — The  attempts  of  nerves 
at  regeneration  after  amputation  form  one  of  the  most  common  examples 
of  false  neuromas.  The  fact  that  these  growths  are  purposive  justifies 
their  classification  as  pseudoneuromas,  otherwise  their  proper  place 
would  be  in  the  group  of  true  neuromas.  As  experimental  transplan- 
tation of  entire  limbs  becomes  possible,  these  regenerative  efforts  on 
the  part  of  the  nerve  may  appear  in  a  new  light.  The  development 
of  fibrous  tissue  seems  merely  to  keep  pace  with  the  ineffectual  though 
purposive  efforts  at  regeneration  by  the  nerve  fibers,  and  it  might  be 
questioned  whether  these  growths  have  a  place  in  the  pathology  of 
true  tumors  at  all.  Borst  now  classes  them  with  the  hypertrophies. 
Identical  processes  occur  in  wounds  of  nerves. 

Macroscopic  Appearance. — To  the  naked  eye  the  false  neuromas 
present  the  appearance  of  fibromas  in  general.  The  smaller  ones  appear 
dense  and  glistening,  the  densit}^  depending  largely  on  the  absence  of 


TKEITMi.Sr   Oi    A  A/   KO.M.IS 


91 


stc()iul;ii\  (.luiiiKes.  Maii\'  of  tin  hii^ir  of  tlusi-  tumors  arc  sciiu- 
HiKruatin<i,  and  on  section  pic-sciit  a  honio^ciu-oiis  moist  ^listcninn 
suit'acf  usualh  paK-  pink  in  color  and  macroscopicall\'  sii^j;cstinfi  m\  xo- 
Hl>r()mas.      In    ilu-   pli  xitorm   auA    traumatic   t\pcs   tin-  direction   ot    tlu- 

hln  I    huiullcs  can  usuall\    hi-  made  out,  and  they  present  a   noduhir  and 

<:n;irKHl  suitace. 

Fig.  28 


v^% 


,^^ 


Microscopic  Appearance.— In  all  the  foregoing  t^pes  the  structure 
is  that  of  fibroma.  The  tissue  is  dense;  the  fibers  are  large  and  less 
closely  arranged  than  in  fibroma,  and  the  cells  more  numerous  and 
rounder.  In  the  solitary  or  multiple  type  found  on  the  peripheral 
nerves  the  fibers  lie  in  interlacing  bands  containing  in  the  meshes  a 
varying  number  of  oval  or  globular  cells.  The  fibers  are  often  pushed 
apart  by  a  myxoid  material  and  present  the  appearance  of  myxofibromas, 
but  give  the  chemical  reaction  of  mucin  imperfectly  or  not  at  all.  It 
is  difficult  to  distinguish  between  connective-tissue  fibers  and  nerves. 
Knauss  has  suggested  teasing  the  fresh  tumors  in  a  solution  ot  osmic 
acid  as  a  means  of  diflferentiation.  When  ganglia  are  the  seat  of  these 
tumors  ganglion  cells  are  found.  They  may  not  differ  from  the  normal, 
but  may  sometimes  show  the  effect  of  compression  and  often  have 
numerous   processes. 

Treatment.— No  general  rules  can  be  given.  Painful  tumors  occupy- 
ing nerves  functionally  unimportant  may  be  excised,  while  those  affectmg 
important  motor  nerves  should  he  undisturbed.  Amputation  neuromas 
should  be  excised. 


CHAPTER     IX 

SARCOMA 

General  Conception. — While  fibromas  represent  a  type  of  newly 
formed  connective  tissue  which  goes  on  to  the  formation  of  purpose- 
less adult  tissue,  sarcomas,  starting  from  morphologically  the  same 
elements,  differ  from  the  fibromas  in  that  they  do  not  reach  the  adult 
stage  of  completely  developed  fibrous  tissue.  They  are  made  up  of 
primordial  fibrous  tissue,  that  is,  of  cells  and  intercellular  substance. 
A  sarcoma  may  be  defined,  therefore,  as  a  tumor  formed  from  the 
connective-tissue  elements,  cells,  and  intercellular  substance,  which  fails 
more   or   less   completely   to   reach    the   state   of  mature   development. 


Fig.  29 


0»^  ^ 


^V 


i ) 


Young  connective  tissue  from  a  healing  wound. 

Imperfect  as  are  the  attempts  at  formation  of  adult  tissue  in  some 
cases,  in  others  the  attempt  is  more  or  less  successful,  giving  rise  to 
admixtures  of  tissue  which  approach  the  adult  nearly  enough  to  be 
recognized  and  identified.  Such  combinations  are  described  by  the 
terms  fibrosarcoma,  chondrosarcoma,  etc.  The  clinical  course  of  these 
tumors  is  modified  usually  by  the  degree  of  maturity  of  the  tissues 
composing  them.  Therefore,  from  the  degree  of  perfection  in  develop- 
ment the  life  history  of  the  tumor  may  be  inferred. 


STRlCri  Rl.   Ol    S.IRCOM.I  93 

Structure.  Since  sarcomas  arc  foriiutl  of  immaiinc  connective 
tissue,  we  may  ex|Hcr  to  HncI  tluii  proror\  jx-  in  emhrvonal  or  develop- 
ing connective  tissiu-.      In  the  latter  particular!)'  do  we  find  the  nearest 

I'iG.  30 

'  '       o  '  <•      - 

:        '  «••'*■  ®  *-    '' 

•     "♦•*.■- 
•'     •-»'.•«>,>?•>  ft 


Young  granulation  tissue,  corresponding  to  a  round-celled  sarcoma. 

approach  to  sarcoma  structure.  More  than  this,  it  is  highly  probable 
that  sarcoma  develops  from  such  tissue  which,  failing  for  some  reason 
to  attain  maturity,  tends  to  unlimited  growth.  The  primal  elements, 
cells,  intercellular  fibrillae,  and  bloodvessels,  are  observed  in  all  develop- 


FiG.  31 


^ 


Old  granulation  tissue,  corresponding  to  a  fibrosarcoma. 

ing  connective  tissue  (Fig.  29).  A  preponderance  of  cells  indicates  a 
primitive  state,  while  a  preponderance  of  fihrdlae  indicates  a  more  mature 
state,  of  development.      In   the   immature   states    the   bloodvessels   are 


94  SARCOMA 

mere  channels  lined  by  endothelium.  In  the  very  early  states  even 
the  endothelial  cells  are  absent  and  the  bloodvessels  are  mereh^  channels 
among  the  cells  (Fig.  30).  As  the  tissue  attains  maturity  the  vessels 
acquire  a  connective-tissue  sheath  (Fig.  31).  The  life  history  of  develop- 
ing connective  tissue  is  reflected  in  the  biology  of  sarcomas.  The  more 
primitive  of  these  tumors  correspond  closel}^  to  the  earlier  stages  of 
developing  fibrous  tissue,  while  the  more  highly  organized  types  of 
tumors  correspond  to  the  more  full}^  developed  fibrous  tissue.  There  is 
no  sharp  dividing  Hne  between  the  more  perfectly  developed  sarcomas 
and  the  fibromas. 

Sarcomas  of  all  types,  therefore,  are  but  variations  of  the  same 
structural  plan,  and  it  remains  to  study  the  various  combinations  which 
the  mature  and  immature  tissues  present.  In  order  to  do  this  more 
clearly  it  is  convenient  first  to  study  separately  the  various  elements 
which  go  to  make  up  the  tumors.  These  elements  are  fibrous  tissue 
(stroma)  and  cells  (parenchyma). 

Connective  Tissue  (Stroma). — With  the  connective  tissue  of  sarcoma 
it  is  convenient  to  include  the  bloodvessels,  and  since  they  are  usually 
very  conspicuous  they  may  be  considered  first.  The  bloodvessels  are 
composed  of  a  very  delicate  tube  of  connective-tissue  fibrils  lined  with 
endothelium.  This  endothelium  is  usually  higher  than  that  lining 
normal  bloodvessels,  and  the  nuclei  project  into  the  lumen.  In  the 
smaller  vessels  the  cells  frequently  form  a  nucleated  syncytium,  which 
may  surround  the  vessel  for  a  considerable  distance.  The  amount  of 
connective  tissue  in  the  vessel  walls  is  usualh^  in  proportion  to  that 
existing  among  the  sarcoma  cells.  When  this  is  demonstrable  with 
difficulty  it  is  usually  hard  to  detect  about  the  bloodvessels,  and  may 
require  special  methods.  Van  Gieson's  or  Mallory's  stain  demon- 
strates the  larger  of  the  fibrils,  but  a  complete  demonstration  can  be 
made  only  by  digesting  out  the  cells  according  to  Mall's  method.  The 
more  rapidly  growing  tumors  may  be  composed  in  some  areas  entirely 
of  cells.  In  such  regions  the  bloodvessels  are  merely  channels  among 
the  cells,  and  it  may   be  impossible   to   detect  fibrils   by  any  method. 

Everywhere,  except  in  certain  areas  of  the  most  rapidly  developing 
tumors,  fibrils  are  to  be  found  among  the  cells.  They  are  usually  most 
prominent  in  the  region  of  the  bloodvessels  and  extend  from  their  walls. 
Not  all  connective  tissue  found  within  a  sarcoma  is  to  be  regarded  as 
newly  formed;  stroma  from  tissue  of  the  part  invaded  may  come  to  He 
in  the  interior  of  the  growth.  In  this  way  bloodvessels  with  thick 
walls  may  be  found  within  such  tumors.  In  expansile  tumors  all  stroma 
is  newly  formed  and  thick-walled  vessels  are  not  found. 

Parenchyma. — In  the  various  types  of  sarcomas  cells  of  every  grade 
of  development  may  be  found,  from  the  normal  cells  in  the  more  highly 


rorocR.ii'iiic.iL  Ri:i..iri<)\s  or  s.ircom.i  95 

developed  vaiit-tics  to  iiiulifferentiarcd  tMihr\()nal  cells  in  rlu-  rapitll\' 
^rowin^,  siiiall-cclk-d  r\pcs.  (jc'iu'iall\  ,  howc-Ntr,  the-  ctlls  arc  miniature 
i\fn  in  tin-  nioit-  iHiftct  t\  pes  of  tumor  tissue,  and  it  is  to  this  tact 
that  the  tiiulcnc\  to  unhmitid  ^lowth  is  to  In-  ascnhcd.  Usuall)'  the 
cells  are  larji;ei"  and  contain  more  protoplasm  than  normal  cells.  I'hus 
in  the  most  fully  developed  fibrosarcoma  as  contrasted  with  hbrous 
tissue  a  great  variety  of  cell  forms  is  observed.  In  osteosarcomas  the 
bone  cells  a le  uregulaily  arranged,  and  show  \anations  m  size  not  ob- 
served in  normal  bone.  In  man\'  sarcomas  there  is  a  prevailing  kind 
of  cell,  which  ma\'  all  be  small  or  large,  round  or  spindle-shaped;  bur 
usualh  there  are  xanations  in  size  and  toiin.  Different  varieties  ma\' 
be  mingled,  or  one  t3'pe  may  persist  in  one  part  of  the  tumor  while  an 
entirely  different  type  prevails  elsewhere.  This  is  especially  likely  to 
occur  when  one  portion  of  a  tumor  suddenly  begins  to  enlarge  rapidh'. 
On  this  account  study  of  the  forms  and  varieties  of  the  cells  often  indi- 
cates the  life  histoi"\'  of  the  tumor. 

The  cells  multipl}'  for. the  most  part  b\'  mitosis,  direct  division  being 
more  rare,  but  the  process  is  often  varied  from  the  normal,  and  aberrant 
divisions  are  frequent.  These  irregularities  may  furnish  a  clew  to  the 
abnormal  development  of  the  tumor.  The  number  of  mitotic  figures 
observed  in  a  microscopic  field  is  an  index  to  the  rate  of  growth. 

The  cells  of  a  tumor  invanabl}-  originate  from  other  tumor  cells. 
Degeneration  of  a  fulh"  developed  cell  into  a  tumor  cell  probably  does 
not  take  place.  Fibromas  said  to  degenerate  into  sarcomas  may  have 
been  sarcomatous  from  the  beginning,  or  the  malignant  growth  ma}' 
have  sprung  up  within  the  higher  t}'pe  of  tumor.  In  the  latter  class 
of  cases  \oung  connective-tissue  cells  ma}'  fail  to  develop  into  adult 
fibroma  cells  and  may  go  on  to  unlimited  growth,  just  as  granulation 
tissue  following  an  injury  may  retain  its  embryonal  state  together 
with  the  proliferative  capacity  peculiar  to  that  condition.  Certain 
it  is  that  an  individual  cell  w^hich  has  once  attained  full  development 
does  not  itself  become  a  sarcoma  cell,  but  its  descendants  ma\'  do  so. 
In  this  sense,  therefore,  a  tumor  which  has  previousl\'  developed  into 
an  adult  t}'pe  of  connective  tissue  ma}'  become  malignant.  The  phrase, 
if  thus  understood,  may  serve  a  useful  clinical  purpose  without  giving 
offence  to  biological  law^s. 

Topographical  Relations. — Sarcomas  ma}'  develop  wherever  connec- 
tive tissue  is  found,  but  certain  regions  are  especially  predisposed  to 
their  development.  These  are  the  subcutaneous  tissue,  the  intermuscular 
septa,  and  the  periosteum.  The  very  earl}'  stages  of  sarcoma,  unlike 
epithelioma,  have  not  been  studied,  and  we  are  unable  to  describe  their 
mode  of  origin;  but  for  reasons  ahead}'  given  we  may  infer  that  the}' 
begin   as   a   single  point  and   develop   from   this   centre.     The  relation 


96  SJRCOMA 

which  the  tumor  focus  bears  to  the  surrounding  tissue  depends  on  the 
tj'pe  of  tumor.  The  higher  types  of  sarcoma  resemble  in  their  mode 
of  growth  tumors  composed  of  the  adult  state  of  the  type  represented. 
Thus  a  fibrosarcoma  resembles  a  fibroma  in  its  mode  of  growth,  and 
usually  somewhat  in  proportion  to  the  degree  of  perfection  of  develop- 

FiG.  32 
J'-  ft     ^^i.^ 


i\ 

^  A 

X 

t- 

'■^*^ 

.^  ' 

3' 

1 

V 

\  ^ 

1 

^'^. 

^ 

>^"- 

Spindle  cells  invading  muscle. 

ment  of  the  malignant  tumor.  The  higher  types,  therefore,  are  expansile 
in  development,  the  neighboring  tissues  being  pushed  aside  to  form  a 
capsule  which  is  usually  infiltrated  by  tumor  cells.  In  the  more  primi- 
tive types  of  sarcoma  the  disposition  to  expansile  growth  is  less  marked, 
and   in   many  of  the   more  cellular  types   the  surrounding  tissue   may 

be    more  or    less    diflPusely    infiltrated 
Fig.  33  (Fig.    32),    though    in    even    the    most 

_^___^  .^ ^        __  _  __  malignant    a    pseudocapsule     may    be 

ivi-^., ...^^ '" '/^.rr..   ;:;_"''~^    -2     well  marked  (Fig.  33). 

-^--^-^-^'V^     ,-—:-,.  Classification. — For   the   purpose   of 

-^^'Xvv--r-f-:"--?%;^r-^^^^  mmute     study     it     is     convenient    to 

v:':  ;^';:v:;. ■;:-.^-..v .•£;;,•; ;;.vi;v  aiviae    the    sarcomas    into  a    number 

'\y''^l^:ll)\'}li^^.:1^i:-\ii^}:^^;}\';\'^'-^:     of  groups,  keeping  constantly  in  mmd, 

•''^■':'-)^^:'^':\^/i:^fr'^>'^^'\:y/\y.'.      however,     that    there     are     no     sharp 

'° ■''■\^'y.::^y'^y^':<°-^°i'^t^/^''} '']■'■  ■;:.['      dividing  lines.      Some    of   the    tumors 

'  ■    "  •*■  -''^•■-  "    ■      '  '■••-Vr?.    '-<''.      are  made  up   entirel)^  or  principally  of 

Pseudocapsule  formed  by   connec-     one  kind  of  cells,  and  are   everywhere 

tive    tissue    compressed    before    the     similar    in     Structure;     these     are    the 

advancing  tumor.  simple   sarcomas.    In  contradistinction 

to  this  is  the  compound  class  in  which 
the  sarcoma  tissue  is  combined  with  one  or  more  of  the  elemental 
tissues,  or  with  tj'pes  which  at  least  closely  imitate  them. 

Simple  Sarcoma. — Under  this  head  may  be  included  those  types  in 
which  no  part  reaches  a  fully  developed  state  of  connective  tissue, 
and  in  which  a  particular  variety  of  cell  predominates. 


cL.issiin:.iTi(j.\  oi  s./kcoM.is  97 

R()rNi)-ci;i.i.i:i)  Sarcoma.      Tlusf  may  be  divided  into  two  ^roii|)s 
small  round-celled  and  large  roimd-celled  sarcoma. 

(a)  Small  Round-celled  (Fig.  34).  Iliis  type  le.sembles  most  clo.sely 
rhf  c-mhi\()nal  connective  tissue,  riuretori-  the  name  ' 'emhi  \()plastic" 
appliitl  In  kohin.  The)'  are  made  up  ot  small  round  cells  resembling 
rhf  small  mononuclear  leukocytes.  I  he  nucKi  are  round  and  stain 
ticiph  ,  while  the  cytoplasm  is  very  small  in  amount,  so  as  to  be  scarcely 
demonstrable.  It  is  ot  a  very  delicate  nature  and  easil\'  degenerates 
and  leaves  the  nuclei  lying  free;  or  this  disappearance  may  be  due  to 
a  failure  of  the  cytoplasm  to  take  the  stain.  The  intercellular  substance 
is  very  slight  m  amoimt  or  may  be  entnely  absent  o\er  large  areas, 
or  ma\'  present  itself  merely  as  granular  debris.  1  he  stroma  is  ver\' 
scanty,  being  represented  largely  b\'  bloodvessels  which  are  often  merely 
endothelial    tubes  without   an}'   connective   tissue,   or   the  endothelium 


Small  round-celled  sarcoma. 


may  be  lacking  and  tumor  cells  themselves  ma\'  form  the  vessel  wall. 
Large  areas  may  be  imperfectly  supplied  with  bloodvessels,  and  thus 
degenerative  processes  readih'  occur.  Usually  stroma  ma\'  be  demon- 
strated by  special  methods,  particularly  about  the  vessels,  but  in  the 
very  rapidly  growing  tumors  it  ma\-  be  absent  over  large  areas. 

{h)  Large  Round-celled  (Fig.  35). — This  t\pe  resembles  closel}'  in 
general  structure  the  small  round-celled  variety,  but  the  cells  are  larger. 
The  cytoplasm  is  more  abundant  and  is  finel}'  granular  on  account 
of  the  presence  of  gl3cogen  granules.  The  cjtoplasm  is  less  delicate 
than  in  the  small  round  cells  and  the  tumor  in  general  undergoes  second- 
ary degeneration  less  readily.  Man\'  of  the  large-celled  sarcomas  as 
classified  by  older  writers  are  descendants  from  mixed  tumors  and  from 
melanomas. 

Spindle-ceiled  Sarcoma. — This   t\pe    also    has    been    divided    into 
small-celled  and  large-celled  t3pes. 
7 


SARCOMA 


{a)  Small  Spindle-celled  (Fig.  36). — These  tumors  are  more  frequent 
than  the  preceding,  and  usuall}^  less  mahgnant.     The  cells  are  oblong. 


Fig.  35 


,c 


h'  ,  ,  ^  'I      .       »  ,  0[      -     i      '    «<■      . 


Large  round-celled  sarcoma. 


fusiform,  and  usually  stain  clearly.  The  cytoplasm  is  usually  abundant, 
a  fact  difficult  to  demonstrate  in  cut  sections,  but  easily  seen  in  fresh 
teased  specimens.     It   may    be    shown  by    this  means  often  to  extend 

Fig.  36 

^;<  -  /;^-"  ^'r     ^  ^  ; 


Small  spindle-celled  sarcoma.     Some  bundles  of  cells  are  cut  longitudinally  and 

some  transversely. 

several  times  the  length  of  the  nucleus.      Sometimes  two  or  more  nuclei 
may  be  seen.     The  stroma  is  more  abundant  than  in  the  round-celled 


cL.issiric.iTios  or  s.ircom.is  '.)'.) 

sarcomas.  Often  rlu-  ili\  iclin<;  line-  between  stroma  and  spindle  cells  is 
not  sharp  (see  Filirosarcoma).  These  tumors  are  often  well  encapsulated. 
Sometimes  round  cells  are  also  present,  and  in  such  cases  the  two 
varieties  are  inrermin<iled,  esiHciall\  in  the  border  of  the  cell  groups. 
Cross-sections  of  bundles  of  spindle  cells  ma\-  simulate  round  cells,  but 
the  cell  groups  are  sharply  defined,  and  cells  cut  without  the  nucleus 
show  simply  as  protoplasmic  disks.  The  differentiation  between  them 
is  easily  made  by  teasing  bits  of  the  fresh  tissue. 

(b)  Large  Spiudlr-ccUrd  (Fig.  37).-  This  form  of  sarcoma  differs  from 
the  preceding  principally-  in  the  size  of  its  cells.  It  is  seen  oftenest 
about   the  bone  and   intermuscular  fascia. 

Fig.  37 


*A/'>J 


Large  spindle-celled  sarcoma  of  ovary.     Une  bundle  cut  longitudinally,  others  are 
cut  transversel}'.     The  tumor  was  edematous  and  of  low  maHgnancy. 

Mixed-celled  S.arcoma. — In  none  of  the  preceding  classes  are  the 
cells  of  one  shape,  but  usualh"  one  kind  predominates.  Sometimes, 
how^ever,  the  intermixture  of  cell  forms  is  so  great  that  the  selection 
of  a  predominating  t\pe  is  not  possible.  Cell  forms  may  be  inter- 
mingled (Fig.  38)  or  the  form  may  be  similar  but  the  sizes  vary  ( Hg. 
39).  To  such  tumors  the  term  "mixed  cell"  has  been  applied.  Every 
possible  combination  may  be  observed  and  the  character  of  the  tumor 
varies  in  different  parts  as  one  or  another  kind  of  cell  predominates. 

Melanosarcom.a.. — This  is  usually  composed  of  large  round  cells 
plus  melanin  (Fig.   40),  which   ma}-  occur  either  in   the  cells  or  in  the 


100  SARCOMA 

intercellular  substance.     The  pigment  is  not  distributed  regularly,  but 
occurs  in  patches  throughout  the  primary  tumor  and  in  the  metastatic 

Fig   38 


>'^>''  / 


,f:^,.-rj.%^(^. 


Mixed-celled  sarcoma,  containing  spindle  cells  and  round  cells. 

nodules.  The  color  of  the  tumor  may  be  less  intensely  black  than 
the  metastatic  nodules  or  the  reverse  may  be  true.  They  may  arise 
m  any  region  where  pigment  cells  normally  exist. 

Fig.  39 


*- 


^3/     )  ^    ^  ?) 


m 


e^      & 


s& 


(* 


53 


^        H  4^ 


iS>  0 


p. 


^*'.   ^\      ^ 

Mixed-celled  sarcoma,  containing  large  round  cells  and  small  round  cells. 

Lymphosarcoma. — The  relationships  of  these  tumors  are  still  in- 
volved in  much  uncertainty.  It  is  often  impossible  to  distinguish 
between  them  and  certain  diseases  of  the  l3^mph  glands  and  blood. 
They  are  characterized  by  small  round  cells  with  a  very  small  rim  of 


CL.issfric.iTiox  or  s.ircom.is  kh 

protoplasm   (  Fi^.    41),  ami    nsiiiiliK    in    this   respect  the   small    round- 

c-flKd  saiionias.      It   was  lnrnurl\    l)ilu\((l   that    th(\  diflVr  from   rhi-m 

I'k;.  40 


Melanosarcoma  of  li\er:    <-/,  liver  cells;  h,  sarcoma  cells  containing 

melanin. 

Fig.  41 


» ••  ■ ' 


Lymphosarcoma  of  the  neck. 


102  SARCOMA 

by  possessing  a  complete  reticular  tissue,  but  the  recent  researches  of 
Selig,^  with  his  exact  demonstration  of  the  reticulum,  have  shown  that 
this  assumption  is  not  justified.  The  location  of  the  tumor  and  the 
history  of  its  development  are  of  greater  value  in  its  diagnosis  than 
are  the  microscopic  findings.  The  picture  often  changes  when  the 
tumor  escapes  into  the  surrounding  connective  tissue  (Fig.  42).  The 
differentiation  between  lymphosarcoma  and  Hodgkin's  disease  is  often 
made  possible  by  detecting  the  endothelial  and  eosinophile  cells  which 
are  peculiar  to  the  latter.     In  its  later  stages  Hodgkin's  disease  resembles 

Fig.  42 


"»  ./»,,,"'" 

'»-•''»''!' 


*•''      -*JJ=^    «■«     ilX  •'   -'.•■*•'.     .'x    *'o  1''.,. 


Lymphosarcoma  of  cervical  region  infiltrating  periglandular  tissue. 

sarcoma  more  closely,  and  many  writers,  as  Coley^  and  Gibbons,''  have 
sought  to  escape  the  difficulty  by  placing  this  disease  in  the  group  of 
sarcomas.  Many  German  writers  class  them  together  as  malignant 
lymphomas  (see  Tumors  of  the  Neck). 

Giant-celled  (Fig.  43). — In  some  of  the  preceding  types  large 
cells  with  several  nuclei  may  be  seen,  but  the  term  "giant-celled"  is 
reserved  for  those  tumors,  which  are  composed  for  the  most  part  of 
round  or  spindle  cells,  but  which  contain  also  large  cells  with  many 
nuclei,  up  to  a  hundred  or  more,  the  nuclei  being  situated  uniformly 
throughout  the  cell.  These  large  cells  are  not  always  evenly  distributed 
throughout  the  tumor,  but  may  occur  in  irregular  groups.    Their  number 

1  Surg.,  Gynec,  and  Obstet.,  1907,  iv,  319. 

2  New  York  Med.  Jour.,  1907,  Ixxxv,  577. 
^  Amer.  Jour.  Med.  Sci.,  1906,  cxxxii,  692. 


CL.issmciriox  or  s.ircom./s 


lo:i 


varies  greatly.      In  sonu-  rumors  a  consiiliiaMc  propoi  rioii  ot   rlie  area 
may   be  occupied    U\    rlust-  crils,   wliiK-   in   oiluis   onK    occasional   cells 


Kic.  4} 


.*.  V.  ■.;•*  ■■■■■!  :;;bv^,"-^^^' 

^'  .*^  /. «     '        -^F"     /  '  V      ..."  J. 


s    VN 


y  ^.  \^l 


I 


Giant-celled  sarcoma  (epulis).     Giant  cells  and  spindle  cells,  the  latter  making  up  the 

bulk  of  the  tumor. 


Fig.  44 


C3; 


i0>. 


^# 


^^r^ 


g' 


^'^-^ 


^<^^     eS 


.<Q 


■^v-^^^  ■'-  -■«' 


Giant  cells  from  sarcoma  of  tibia. 


are  found.     In  the  distribution  of  the  nuclei  the\'  resemble  the  foreign 
body  giant  cells  (Figs.  44  and  45),  and  also  the  giant  cells  sometimes 


104  SARCOMA 

found  in  syphilis.  Foreign  body  giant  cells  are,  as  the  name  implies, 
found  about  the  foreign  bodies,  which  may  be  extrinsic,  such  as  bits  of 
Hgature,  or  intrinsic,  such  as  degenerative  products.  The  syphilitic 
giant  cells  are  usually  smaller  than  the  sarcomatous,  are  less  numerous 
and  are  attended  by  the  usual  vascular  changes  of  syphilis.  The  giant 
cells  in  tuberculosis  differ  from  these  in  that  the  nuclei  are  arranged 
about  one  pole  or  about  the  periphery  of  the  cell,  and  in  addition  other 
evidences  of  tuberculosis  are  present,  notably  the  necrotic  cell  centre, 
the  endothelial  cells  surrounding  the  giant  cell,  and  finally  the  presence 
of  tubercle  bacilli  within  the  giant  cell. 

Fig.  45 


is> 


m     ^ 


c 

Foreign  body  giant  cell. 

Higher  Types  of  Sarcoma. — Under  this  heading  may  be  grouped  those 
sarcomas  in  which  a  more  or  less  perfect  development  of  one  of  the 
elemental  forms  of  connective  tissue  has  been  attained.  Biologically, 
these  may  be  considered  a  higher  form,  but  clinically  this  is  not  true, 
except  in  a  limited  sense,  for  even  tumors  formed  largely  of  tissue 
which  approaches  closest  the  normal  development  may  nevertheless  be 
characterized  by  early  metastasis. 

Fibrosarcoma  (Fig.  46). — By  fibrosarcoma  is  meant  a  connective- 
tissue  tumor  which  has  gone  nearly  to  full  development,  certain  areas, 
indeed,  presenting  adult  fibrous  tissue  (Fig.  47).  Since  these  tumors 
comprise  the  most  perfectly  developed  sarcomas  the  cells  are  usually 
spindle-shaped,  but  round  cells  may  be  present  in  rapidly  developing 
areas  (Fig.  48).  Spindle  cells  cut  transversely  may  appear  as  round 
cells.  The  nuclei  are  more  prominent  than  in  fully  developed,  fibrous 
tissue  and  the  cytoplasm  is  more  abundant.     The  bloodvessels  come 


IlIiROS.IRCOM.I  105 

in    dirtcr   contact   with    the-    tumor  cills,   though   often    where  the  con- 
ncctiNc  tissue  IS  abundant  this  nia\    not  he-  easily  made  out.     The  Hlu-r 

Vu:.  46 


/  /  / 

/ 


Small  spindle-celled  fibrosarcoma:      a,  cells  cut  longitudinally;   ^,  cells  cut 
transversely;  c,  bloodvessels. 

bundles  sometimes   lie  parallel   to   the  vessels,  but  quite  as  often   they 
diverge  at  a  more  or  less  acute  angle.     The  nuclei  var}'  as  to  the  direc- 

FlG.  47 


c 


Fibrosarcoma  of  popliteal  space,  showing  small  spindle  cells  embedded  in  bundles 

of  fibrous  tissue. 

tion  of  their  long  axis  relative  to  the  direction  of  the  hbers  between  which 
thev  He  and  also  of  the  vessels  near  them.     It  is  just  this  independence 


106  SARCOMA 

of  the  direction  of  the  nuclei,  together  with  their  cytoplasm  that  gives 
the   chief  evidence   of  undeveloped    tissue.      In    many   cases   a   micro- 


Rapidly  growing  area  of  a  fibrosarcoma. 

scopic  differentiation  is  impossible  because  no  distinct  border  line 
between  benign  and  malignant  fibrous  tumors  exists.  Mallory  has 
proposed  that  no  attempt  at  differentiation  be  made. 

Fig.  49 


C 

a 


Chondrosarcoma  (mixed  tumor)  of  testicle:     a,  area  of  cartilage;  b,  sarcoma 
cells;  c,  connective  tissue. 

Spindle-celled    sarcomas    are    often    called    fibrosarcoma    because    the 
cell  processes  may  appear  as  fibrils.     Often  the  relation  of  cell  to  fibers 


CIIOXDROK.IRCOM.I  1(17 

is  not  fasil\  iiiadr  out  iink-ss  specMal  stains  tlu-  ht-st  of  \slin.h  is 
Mallon's     are  ciiiplo)  ctl. 

I'he  more  nearh  Hhrosarconias  iniitatt-  tlu-  |)ure  hbroiiias  in  structure 
the  more  nearly  the\  imitate  them  in  ehnical  course.  Often  the  clinical 
course  and  the  location  of  the  tumor  ma}^  give  evidence  of  importance. 
In  addition,  it  must  he  rememhered  that  a  given  tumor  ma}'  show  some 
areas  which  are  composed  of  fully  developed  connective  tissue  while 
other  areas  ma\-  he  distinctly  sarcomatous.  In  no  tumor  does  the 
examination  of  onl)'  a  single  part  lead  so  often   to  error  as  in   these. 

Chondrosarcoma. — These  tumors  are  composed  of  cartilage  and 
sarcomatous  tissue  (Figs.  49  and  50).  I'hey  are  most  commonly 
observed  as  a  part  of  mixed  tumors,  e.  g.,  of  parotid  and  testicle,  but 
thev  occur  also  in  sarcomas  of  bone.  Chondrosarcomas  are  formed 
b}-  the  deposit  of  a  h3'aline  intercellular  substance  about  sarcoma  cells 
which    have    originated    from    the    osteogenic    membrane.      The\'    bear 

Fig.  50 


Chondrosarcoma.     Sarcoma  cells  in  centre,  cartilage  at  the  right. 

an  imperfect  resemblance  to  normal  cartilage.  The  number  of  cells 
in  the  lacunae  varies  from  one  to  man}',  and  they  are  arranged  irregu- 
larh'.  The  intercellular  substance  varies  much  in  amount  and  there 
are  frequently  large  areas  without  cells.  The  cartilaginous  parts  are 
usualh'  easily  detected  because  of  their  densit}-  and  the  pale  blue 
glistening  surface.  Tumors  often  appear,  on  superficial  examination, 
to  be  pure  chondromas;  but  if  they  grow  rapidly  one  should  search 
persistently  for  malignant  areas.  These  will  be  characterized  b\-  the 
irregular  arrangement  of  the  cartilage  cells  withm  them  and  b}'  their 
border  of  groups  of  cells  without  intercellular  hyaline  substance,  and 
with,  perhaps,  a  number  of  thin-walled  vessels.  Often,  however,  the 
most  careful  search  fails  to  reveal  sarcomatous  areas,  and  }et  the  tumor 
IS  clinicall}'  malignant. 

Chondrosarcomas    frequentl}'    have    osseous    areas    in    their    centre, 
particularh'  in  the  more  slowly  growing  tA'pes,  and  are  then  called  osteo- 


108  SARCOMA 

chondrosarcomas  (Fig.  51).     The   disposition    to   bone  production  may 
be  regarded  as  the  normal  tendency  in  the  higher  types  of  chondro- 

FiG.  51 


,^     > 


a 


y 


4. • 


-d 


\ 

Osteochondrosarcoma  of  rib:    a,  bone;  b,  cartilage;  c,  connective  tissue. 

sarcomas.      A    calcareous    infiltration    which    resembles    ossification    on 
macroscopic  examination  is  sometimes  found  in  the  centres  of  degener- 

FiG.  52 


a- 


a 


Periosteal  osteosarcoma:    a,  bone  trabeculae;  b,  sarcoma  cells. 

ating  chondrosarcomas.     The  addition  of  an  acid  will  differentiate  these 
from  ossified  areas. 


osri'.os.ikcoM.i  109 

OsTKosARCOMA.  7luse  tiniiors  may  spiinji  eitlur  from  rlu-  peri- 
osteum or  from  rlu-  medulla,  and  are  seen  most  tVequentlv  in  the  lonj; 
bones,  pai  ru  iil;irl\  near  the  joints.  When  they  grow  from  rlu-  periosteum 
they  c-ncircK-  rlu-  hone  aiul  i-xrend  along  the  shaft.  'I'hey  may  be  com- 
posed of  small  round  cells  (Figs.  52  and  53),  spindle  cells,  or  giant  cells 
(  I'ig.  54),  and  rend  ro  form  large  masses  which  are  fusiform  or  bos- 
selated.  I  lu-  nu-(.lulhir\  type  begins  as  a  globular  mass  which  graduall\' 
invades  the  bone  from  within  until  the  periosteum  is  perforated.  1' re- 
quenth-  the  periosteum  attempts  to  limit  the  growth  by  throwing  out 
a  shell  of  normal  bone.  After  a  time,  however,  the  tumor  reaches  the 
soft  parts  and  rhe  growrh  is  usuall\-  rhen  more  rajiul.  1  he  tumor  ma\' 
extend  along  the  medullary  cavity  for  a  considerable  distance  before 
perforating  the  bone.     Giant-celled  sarcoma  of  the  medulla  ma\-  undergo 


Fig.  53 

» 

• 

®        .    .-w  ■ 

4>, ..-           •»  ••  -f 

•*/ 

•        e 

^             '  ^      .^    " 

J              ^' 

■  k 

"'  i, 

«     ./.'■' 

^                              K 

'    0     ' 

0 

,* 

"     ■                     fl 

"      „            i                        - 

%V  ' 

6   '^      ■  ./S?^  ^ 

*■;    " 

■    ' 

Myelogenous  osteosarcoma. 

secondary  changes  from  hemorrhage  into  its  substance  or  otherwise, 
and  become  c\stic.  The  sarcomatous  element  ma\-  so  far  disappear 
that  the  true  nature  of  the  tumor  may  be  difficult  to  determine.  This 
is  particularly  true  in  the  so-called  bone  c\-sts  which  Gaylord  has 
recenth'  shown  to  be  always  giant-celled  sarcoma  which  have  under- 
gone such  secondary  changes.  The  bone  sarcoma  ma}-,  like  the  cartilage 
sarcoma,  be  made  up  largel\'  of  cellular  elements,  with  but  a  small  amount 
of  the  more  highly  developed  tissue;  or,  on  the  other  hand,  the  tumor 
may  be  composed  almost  entireh"  of  bone  with  few  recognizable  sarcom- 
atous areas.  In  the  former  case  the  bone  is  arranged  as  spicules  which 
may  extend  out  into  the  soft  tissue  and  upward  from  the  bony  base 
and  lie  free  in  the  tumor  without  such  bon\-  connection.  The  usual 
structure  is  a  homogeneous  groundwork  containing  bone  cells.     1  here 


no  SARCOMA 

are  usually  no  Haversian  systems,^  but  attempts  at  the  formation  of 
a  medullary  cavity  have  been  noted  (v.  Hansemann,  Borst).  The 
bony  spicules  must  be  differentiated  from  areas  of  calcareous  degenera- 
tion of  cellular  tumors.  In  the  more  completely  ossified  types  pro- 
longed search  may  fail  to  show  mahgnant  areas.  Their  slow  growth 
likewise  may  further  tend  to  suggest  pure  osteoma.  Nevertheless, 
metastasis    may    occur    and    give    rise    to    fibrosarcomas    and    chondro- 

FiG.  54 


-b 


.  K 


t     ) 


\ 


A', 
\  • 


-a 


* ,  I 


«.    X 


.<i    i.^ 


Giant-celled  osteosarcoma  of  tibia:    a,  bone  spicules;  b,  giant  cells;  c,  spindle  sarcoma 


cells. 


sarcomas.  The  external  form  of  the  tumor  and  the  site  and  circum- 
stances of  its  growth  may  give  valuable  evidence  as  to  its  biological 
nature. 

Myxosarcoma. — These  tumors  are  myxomas  which  contain  rapidly 
proliferating  cells.  Most  of  the  cells  are  fusiform  or  stellate,  but  areas 
of  round   cells   may   be   present,   and   in   the   myxomatous   intercellular 

'  Brauld,  Article  Sarcoma,  Manuel  d'Histologie  pathologique,  Cornil  et  Ranvier, 
3d  edition,  vol.  ii,  p.  321. 


MVXOS.fkCOM.J 


111 


substance  rtbrils  arc  often  seen.  Sarcomas  of  other  t\pes  which  have 
iiiuler<i:()ne  a  secoiular\'  niyxoniatoiis  cle<ieiieiation  are  often  incorrectK' 
|">lacetl    m    this    uroiip,    which    should    uulutlc-   onl\     those    in    which    the 


l-K,.  5: 


-A  4. 


r 

,      6  :     ' 

X 

'     Ct; 

\ 

1     '^ 

V 

)|l 

/ 

V 

\ 

\ 

\ 

\ 

\ 

V 

i 

^ 

J, 

1 

^ 

V 

\ 

• 

t 

\ 

V 

\         \ 

V 

\ 

-  \ 

Myxosarcoma. 

myxoid  cells  are  actively  proliferating  (Fig.  55).  The  myxosarcomas 
may  present  only  slight  evidence  of  malignancy.  Frequently,  rapidly 
growing   tumors  composed   of  myxoid   tissue  will   recur  after   removal 

Fig.  56 


Glioma  of  retina  (gliosarcoma). 


when  no  definite  areas  of  sarcoma  can  be  demonstrated  m  them.  Here 
agam  the  life  histor\'  and  topography  must  be  considered  m  order  to 
interpret  correctly  the  microscopic  findings. 


112  SARCOMA 

Gliosarcoma. — These  tumors  are  characterized  by  rapid  proHfera- 
tion  of  glia  cells.  They  contain,  in  addition,  various  other  kinds  of 
cells — round  cells  of  various  sizes,  polymorphic  epithelioid  cells,  cells 
with  processes,  and  cells  without  (Fig.  56).  Ribbert  is  disposed  to 
class  such  tumors  with  the  gliomas.  This  seems  justified  in  those  cases 
in  which  the  cells  have  attained  the  normal  degree  of  development 
and  are  abnormal  onl}^  in  the  rate  of  growth.  The  segregation  of  the 
malignant  glia  tumors  from  the  sarcoma  group  is  justified  further  by 
the  fact  that  the  glia  cells  are  epiblastic  in  origin.  In  their  general 
characteristics  these  tumors  resemble  the  malignant  myomas,  which 
in  turn  closely  resemble  malignant  tumors  of  connective-tissue  origin. 
It  is  convenient,  therefore,  to  include  the  rapidly  growing  tumors 
springing  from  glia  cells  in  the  sarcoma  group,  notwithstanding  the 
more  dignified  ancestry  of  the  glia  cells. 

Fig.  57 


Liposarcoma. 

LiPOSARCOMA. — Von  Recklinghausen  described  under  this  head  those 
sarcomas  in  which  a  large  number  of  the  cells  become  filled  with  fat 
(Fig.  57).  They  may  be  distinguished  from  the  cases  in  which  fat  is 
included  in  a  tumor  by  infiltration,  by  the  fact  that  in  the  true  lipo- 
sarcomas  the  fat-containing  cells  vary  much  in  size,  while  in  the  latter 
case  the  cells  are  more  nearly  uniform.    They  are  very  rare. 

Angiosarcoma. — The  present  disposition  is  to  classify  those  tumors 
which  were  formerly  called  angiosarcomas  with  the  endotheliomas  or 
more  particularly  the  peritheliomas.  The  most  of  the  tumors  placed 
under  this  head  by  Waldeyer  would  now,  no  doubt,  be  regarded  as 
perivascular  endotheliomas  by  most  pathologists.  If  the  term  is  re- 
tained it  should  be  limited  to  those  sarcomatous  tumors  in  which  the 


MYOS.IRCOM  I  \V.\ 

cells  spriiii;  out  litim  \\\c  vtsst.1  \\;ill.  It  is  possihli-  iliar  ctlls  spmi^iiii^ 
fn)m  tin-  pri  i\  ;ist.ul;ii  iiulotluliiiin  iii;i\'  fiivi-  nsf  to  tiiinors  which 
cxccid  tin-  pn  iilulioiiKis  in  m;ili<;ii;iMc\  .  Such  a  view  would  be  usetui 
ill  clinical  chissiticiitioii,  ;intl  in  \  icw  ot  the  uiiceiraui  liiiiits  ot  the 
LMolojiical  i^ossihilitits  of  the-  cndotluhal  cell  lued  j^inc  no  ottcnce  to 
theoretical  conceptions.  I  In-  nuinhi  r  and  si/e  ol  the  \essels  in  sarcoma 
and  theii  arranj;eiiunr  m  nlation  to  tin-  cells  do  nor  warrant  the 
desi liquation  angiosarcoma. 

MYOSARCOMA  (  Fifi.  58).-  In  m\()nias  ln(|uciul\  rlie  cells  ol  ceiram 
areas  undergo  rapid  proliteiarion.  I' or  rlu-  most  |iair  rlu\  retain  a 
spindle  shape  and  form  Inindks  which  like  the  myoma  cells  are  arranued 
parallel  to  the  vessels.  The  nuclei  are  larger  in  size  than  the  muscle- 
celled  luicki.  Init  in  general  the  structure  and  the  tinctorial  reaction 
of    muscle    is    retained,    though     rapid     growth     and     the    formation    ot 

Fic.  ;8 


\h"Osarcoma  of  the  uterus. 

metastases  take  place.  These  are  called  malignant  myomas.  Areas  are 
frequently  encountered  in  which  nuclei  of  ver}'  different  sizes  dis- 
regard all  relation  to  the  direction  of  the  bloodvessels.  It  is  this  type 
that  is  said  frequenth^  to  undergo  a  sarcomatous  degeneration.  Leio- 
myomas are  often  found  in  which  the  deviation  is  still  greater;  these 
are  myosarcomas.  Still  greater  deviation  results  in  tumors  which 
parallel  those  derived  from  connective  tissue.  Since  in  rare  instances 
so-called  malignant  myomas  are  encountered  in  which  the  cells  retain 
at  first  the  form  of  a  normal  non-striated  muscle  cell  and  deviate  only 
in  the  rapidit\-  of  their  multiplications,  it  seems  quite  possible  that  in 
this  rapid  proliferation  the  cells  would  fail  eventually  to  attain  perfect 
development.  In  such  cases  we  might  well  speak  of  an  actual  sarcom- 
atous degeneration.  We  mean  by  this  not  that  a  myoma  cell  once 
having  attained  full  development  reverts  to  a  lower  form,  but  that 
8 


114  SARCOMA 

descendants  of  such  cells  fail  to  attain  full  development.  In  speak- 
ing of  a  degeneration  of  myoma  into  a  myomasarcoma  we  must  think, 
therefore,  of  the  tumor  as  a  whole,  and  not  of  the  individual  fiber. 
In  this  way  we  may  harmonize  clinical  experience  with  pathological 
findings  without  doing  violence  to  any  biological  law.  Many  path- 
ologists who  are  reluctant  to  admit  the  possibility  of  such  a  degree  of 

Fig.  59 


Myosarcoma  of  the  uterus.      Simple   myoma   below,   malignant   transformation — 

the  upper  part  of  the  cut. 

metaplasia  believe  that  the  sarcomas  appearing  in  myomas  arise  from 
the  connective  tissue  of  the  myoma  or  that  the  entire  tumor  was  sar- 
comatous from  the  beginning.  There  is  much  evidence,  both  clinical 
and  microscopic,  which  warrants  the  belief  that  sarcomas  do  develop 
from  muscle  cells. 

In  structure  these  tumors  present  every  variation  from  muscle  cells, 


.njKOl.lR  S.IRCOM.I 


115 


sliowinii,  tlu'  sli;i,lu  th;iii<;is  :il>()\'f  noti-ci  to  cells  l>c-wiin^  no  resenibhinct- 
to  iiuiscif  cells  sri  ucrui;ill\    or  riiicrori;ill\    ( Kigs.   59  aiul  60).     L  suallv 


Kk;.  60 


-  (.-/*■-      ;    r?5 


M\'osarc()nia,  showing  the  \ariation  in  the  size  and  shape  of  the  nuclei. 


f'iG.  61 


^'Sir-cvv e?-o_^'  '<iQ'<s;'  -^ ' 

'^  e^  -       IS)  ^^       \<^  ^^ Sj  ^      '"v* 


the  cells  are  large,  with  oval  nuclei  and  abundant  protoplasm,  but 
in  ver}'  rapidly  growing  tumors,  particularly  recurrences,  small  round 
cells  with  little  protoplasm,  with  little 
stroma,  and  few  vessels  may  make  up 
the  entire  volume  of  the  tumor. 

Alveol.a.r  Sarcom.a.  (Fig.  61). — Form- 
erh'  tumors  with  intercellular  connective 
tissue  which  were  arranged  in  alveolae 
w^ere  classed  with  the  sarcomas  under 
this  heading.  The  most  of  these  tumors 
are  now  definiteh'  classed  with  the 
endotheliomas.  Frequently  when  mixed 
tumors  become  malignant  they  have 
this  arrangement,  the  cells  in  such 
tumors  being  considered  by  man}'  pathol- 
ogists to  be  endothelial  in  origin.  \\  hen 
all  such  tumors  are  taken  into  account 
there  still  remain  some  alveolar  tumors 
which  seem  to  be  essentially  sarcoma- 
tous. The  term  ma}',  therefore,  be  tentativel}'  retained  pending  a 
renewed  stud}'  of  these  tumors. 


-O^r 


-^j<^. 


.■^'^', 


Alveolar  sarcoma. 


116  SARCOMA 

Sarcocarcinomas. — In  rare  tumors  occurring  chiefly  in  the  uterus, 
typical  carcinomatous  areas  are  interspersed  with  connective  tissue 
composed  of  spindle  cells.  These  tumors  run  the  course  of  carcinomas 
apparently  uninfluenced  by  the  peculiar  character  of  the  connective 
tissue.  That  the  connective  tissue  may  become  the  dominating  ele- 
ment is  shown  by  the  gradual  loss  of  the  epithelial  elements  in  some 
transplantable  animal  tumors.  There  is  no  evidence  that  this  takes 
place  in  human  tumors,  but  the  possibility  cannot  be  denied. 

Macroscopic  Appearance. — Sarcomas  on  section  are  white  or  grayish 
white  in  the  cellular  varieties,  pinkish  white  in  the  fibrillar  varieties, 
and  red  or  reddish  brown  in  the  giant-celled  varieties.  The  higher 
types  may  resemble — in  fact  may  be  macroscopically  indistinguish- 
able from — the  tissue  they  represent.  This  is  particularly  true  of  the 
myxomas,  chondromas,  and  osteomas.  Usually  they  are  pinkish  white, 
glistening  on  section,  and  are  generally  homogeneous  except  in  very 
vascular  areas  where  the  vessels  may  be  seen.  In  fibrosarcoma  bands 
of  fibers  simulating  those  in  fibromas  may  be  noticed.  Degenerated 
areas  may  be  observed.  In  consistency  they  vary  greatly.  The  very 
cellular  tumors  are  soft  and  brain-like,  the  fibrous  types  are  firm,  and 
the  density  of  cartilaginous  and  bony  tumors  depends  on  the  propor- 
tion of  those  tissues  present.  Modifications  in  the  gross  appearance 
of  sarcomas  often  occur  through  some  accident  in  their  development. 
Hemorrhage  into  their  substance  gives  them  a  deep  red  color.  ^  Such 
areas  may  soften  and  form  cysts  filled  with  a  reddish  or  straw-colored 
fluid. 

Retrogressive  Metamorphosis. — Lipomatous  Degeneration. — This  type 
of  degeneration  occurs  rather  frequently.  It  must  be  distinguished 
from  the  rare  liposarcoma  and  from  inclusions  of  fatty  tissue.  The 
degeneration  usually  takes  place  in  the  centre  of  the  tumor  where  the 
nutrition  is  poorest,  and  generally  gives  a  yellow  moist  appearance 
to  the  area  involved.  The  cells  are  usually  indistinct  or  entirely 
destroyed,  which  does  not  occur  with  liposarcoma,  nor  with  fat  inclu- 
sion. In  cases  of  fat  inclusion  the  vessels  and  fibrous  tissue  present 
usually  leave  no  doubt  as  to  the  source  of  the  fat.  In  fatty  degenera- 
tion complete  liquefaction  with  cyst  formation  is  common,  and  hemor- 
rhage may  or  may  not  occur. 

Myxomatous  Degeneration  (Fig.  62). — This  is  one  of  the  common 
types  of  degeneration  and  occurs  in  the  centre  of  many  of  the  rapidly 
growing  tumors.  It  should  be  distinguished  from  myxosarcoma.  In 
the  degenerated  area  the  cells  are  not  fusiform  nor  stellate;  the  inter- 
cellular substance  is  homogeneous  and  translucent,  but  in  the  border 
of  the  area  portions  of  the  sarcomatous  tissue  can  be  seen  to  have  under- 
gone myxomatous  change,  while  other  neighboring  tissue  has  escaped. 


kj:TR(M;k/:ssn  /:  Mi/r.iMoRrnosis  1 17 

Areas    of    iiiyxoiiKiroiis    (Iciiciuiaiioii    f it(]ii(nil\     iiiuici^o    li<iiitl:uti()n 
and  cyst  (oi  inarion. 

Fic.  62 

/:■     ■  •'■■    ■  -   \:-.'    \ 

'J  '  "        I    ■     . , ' 

f'.'         ■     „?/ -"'V,  ^.v\-     -        j 


Myxoniarous  desenerarion  of  fibrosarcoma  of  the  ovary,  showing  s|iindlc  cells  and 

myxomatous  tissue. 

Calcareous  Degeneration. — This  t\pe  of  degeneration  is  most  likely 
to  take  place  in  the  slowh'  growing  tumors  with  imperfect  nutrition. 
It  IS  usually  preceded  by  some  other  type  of  degeneration  and  must 
be  regarded  as  a  terminal  result.  It  presents  dense  irregular  masses 
which  are  eas}'  to  recognize. 

Fig.  63 


Edematous   fibrosarcoma   of  the  o\ary.  sliowing  spindle  cells  and   fibrous   bundles 

pressed  apart  by  fluid. 

Edema  (tig.  63). — When  the  circuhition  is  parth-  obstructed  tumors 
frequent!}'  become  edematous.  This  ma\'  be  mistaken  for  rapid  growth 
and  malignancy.  It  usually  gives  a  whitish  and  more  translucent 
appearance  to  the  tumor. 


118  SARCOMA 

Necrosis. —  It  is  quite  common  in  a  rapidly  growing  sarcoma  to  find 
an  area  of  necrosis.  It  may  be  limited  in  extent,  as  in  tuberculosis 
or  syphilis,  or  it  may  be  diffuse,  involving  a  considerable  area  of  the 
tumor.  The  former  occurs  most  frequently  in  the  so-called  round- 
celled  sarcoma  of  the  testicle  and  in  the  lymphosarcoma  (Fig.  64), 
while  the  latter  is  especially  likely  to  occur  in  sarcoma  of  the  ovary. 
The  necrosis  is  due  either  to  the  failure  of  sufficient  vessels  to  develop 
to  supply  the  part  or  to  occlusion  of  the  supplying  vessel.  In  the  latter 
case  the  occluded  vessel  may  sometimes  be  seen.  The  necrotic  areas 
may  be  grayish  white  or,  if  hemorrhagic,  grayish  black,  and  are  usually 
moist  in  appearance.  The  sarcoma  may  reach  the  surface  and  form 
an  ulcer.  Tumor  tissue  thus  exposed  readily  becomes  infected,  and 
owing  to  its  low  resistance  may  rapidly  develop  deep  necrosis. 

Fig.  64 


Lymphosarcoma  of  mediastinum,  centre  retained,  periphery  degenerated. 

Cyst  Formation. — In  any  of  the  previous  degenerations  liquefaction 
may  occur  with  subsequent  cyst  formation.  Hemorrhage  mto  the 
interior  of  the  tumor  may  result  from  the  weakened  vessel  walls.  Such 
cysts  may  be  filled  with  dark,  greenish,  or  straw-colored  fluid,  depend- 
ing on  the  degree  of  change  in  the  escaped  blood.  Cysts  with  clear 
fluid  are  sometimes  found  in  tumors  supposedly  sarcomatous  in  char- 
acter, which  are  probably  really  mixed  tumors,  the  cysts  being  the 
product  of  gland  epithehum.  Cystosarcoma,  the  term  usually  apphed 
to  such  conditions,  is  probably  a  misnomer. 

Metastasis. — Sarcomas  are  preeminently  metastasizing  tumors,  and 
it  is  in  this  way  that  they  show  most  plainly  their  mahgnancy.     As 


i)/.n;.\os/s  Of  s.ircom.i  iiu 

a  class  tlicy  ni;i\  Ix  s;ii(l  to  iiKtastasize  by  \va\'  of  rlic  l)l()()cl vessels. 
It  was  foniuilv  thought  tli;it  the  close  pnjximity  of  the  cells  to  the 
vessels  ami  rhi  thiiiiuss  of  riu-  walls  were  suHicient  to  account  for  the 
tirtiiKiuv  of  \;istiilai  nut ;(sr;i.sis,  howcxci  this  m;i\  iu-,  luuci  sfiuhes 
seem  to  iiulicare  that  the  cheiimal  constitution  of  tumor  ceils  hears 
an  impoitant  part  in  tlctermmm^  the  region  of  predilection  in  meta- 
stasis tormution.  i,\  ni|iharic  metastasis  is  rarely  seen  in  sarcoma, 
if  the  lymphomas  are  excluded  from  the  sarcoma  group.  Retrof^rade 
metastases  are  sometimes  observed  in  rapidl\'  growinji;  tumors.  Ihe 
different  Narieties  of  sarcoma  possess  the  tendency  to  form  metastases 
m  \aii()us  degree.  The  round-celled  types,  particulaih'  the  melanotic, 
are  most  likel\'  to  metastasize,  while  giant-celled  and  Hbrous  types, 
particularh'  the  former,  show  but  little  tendencv  in  this  direction. 
The  regions  of  predilection  for  metastases  are  the  lungs  and  the  liver, 
though  no  region  or  organ  is  exempt.  It  is  not  uncommon  to  see  cases 
in  which  hundreds  of  tumors  are  distributed  throughout  the  bod\'. 
The  existence  of  hepatic,  pulmonary  or  cerebral  disease  in  the  presence 
ot  tumors  should  always  suggest  the  probability  of  metastasizing  sar- 
coma. The  failure  to  recognize  this  condition,  a  frequent  error,  often 
leads  to  useless  operations  upon  the  primar\'  tumor. 

Constitutional  Disturbance. — The  constitutional  disturbance  pro- 
duced by  sarcoma  does  not  usuall\'  become  prominent  early.  When 
the  tumor  has  become  large  or  metastases  have  formed  the  disturbance 
ma\'  become  proiound.  The  blood  changes  are  frequently'  extensive 
and  correspond  in  general  to  those  of  anemia  rather  than  to  cachexia 
as  observed  in  cancers.  A  rise  of  temperature  even  to  104°  is  not  un- 
usual. Corresponding  to  this  there  is  an  increase  in  leukocytes  quite 
as  high  as  in  suppurative  processes.  I  have  observed  one  case  in  which 
there  were  lung  metastases  with  48,000.  In  lymphosarcoma  the  possi- 
bility of  confounding  the  disease  with  leukemia  should  alwa\s  be  kept 
in  mmd.  After  the  temperature  rises  the  constitutional  disturbances 
develop  rapidly.  The  constitutional  effects  are  probabh'  due  to  the 
poisons  eliminated  by  the  growing  cells. 

Cause  of  Death. — Sarcomas  being  primarily  tumors  of  the  connec- 
tive tissue,  and,  therefore,  in  regions  remote  from  vital  organs,  death 
is  brought  about  by  the  secondary  tumors  which  develop  in  paren- 
chymatous organs,  and  less  often  than  in  cancer  bv  the  direct  effects 
at  the  primary  seat  of  the  tumor.  It  is  necessary  to  consider  the  exact 
character  of  a  particular  tumor  and  the  previous  rate  of  growth  in 
order  to  forecast  the  time  and  manner  of  death. 

Diagnosis.  -Clinical  Diagnosis. — Sarcomas  are  usuall\'  rounded  or 
bosselated  tumors,  \arymg  in  consistency.  On  section,  in  the  absence 
of  degenerative  processes,  they  are  usually  whitish,  pinkish,  or  gra3ish. 


120  SARCOMA 

The  rounded  form  ma}"  be  lost  in  the  very  infiltrative  t3^pe,  particularly 
in  tumors  going  out  from  the  periosteum;  but  even  m  these  cases  a 
sharper  limitation  of  the  border  can  be  made  out  than  would  be  the  case 
in  an  inflammatory  process  of  the  same  region.  The  rounded  form  is 
sometimes  disturbed  by  extensive  degenerative  processes,  particularly 
ulcerations.  The  color  is  different  in  certain  types,  the  darker,  even 
black,  color  of  the  melanotic  tumors  and  the  deep  red  color  of  the  giant- 
celled  varieties  being  common  examples.  The  changes  m  color  ma}^ 
be  due  to  degenerative  processes.  Extensive  myxoid  degeneration  may 
lead  to  the  suspicion  that  the  entire  tumor  is  composed  of  the  simple 
tissue.  Hemorrhage  into  the  interior  may  hide  the  real  structure. 
Both  these  processes  may  reduce  the  tumor  to  a  cyst,  m  the  walls  of 
which  sarcomatous  tissue  may  be  demonstrated  with  difficulty. 

The  rate  of  growth  is  an  important  element  m  the  recognition  of  a 
sarcoma.  In  general  it  may  be  stated  that  a  rapidly  growing  tumor 
of  connective-tissue  origin  is  a  sarcoma.  This  point  usually  permits 
an  exclusion  of  the  epithelial  neoplasms,  but  it  does  not  differentiate 
from  the  inflammatory  processes.  On  the  other  hand,  certain  sarcomas 
may  grow  so  slowly  that  a  benign  nature  may  erroneously  be  attributed 
to  them.  A  definite  knowledge  of  the  kind  and  situation  of  the  tumors 
likely  to  occur  in  the  part  affected  is  necessary  for  diagnosis.  Fre- 
quently, after  long  periods  of  slow  growth,  these  tumors  may  suddenly 
develop  rapidly,  and  in  such  cases  a  sarcomatous  degeneration  of  a 
previously  benign  tumor  is  often  assumed.  The  nature  of  these  slow 
growing  tumors  should  be  determined  in  every  case  before  the  rapid 
growth  begins.  Degenerative  changes  in  a  benign  tumor  may  simulate 
rapid  growth,  a  frequent  example  of  which  is  hemorrhage,  or  sudden 
edema  of  a  myoma.  It  may  be  remarked  in  passing  that  a  supposedly 
benign  tumor  which  is  the  seat  of  a  degenerative  process  should  be 
regarded  with  grave  suspicion,  even  though  the  microscope  fails  to 
reveal  sarcomatous  tissue. 

Microscopic  Diagnosis. — The  microscopic  diagnosis  depends  on  the 
recognition  of  a  connective-tissue  tumor  which  fails  in  whole  or  in 
part  to  reproduce  adult  connective  tissue.  The  problem  of  differen- 
tiation, therefore,  lies  in  distinguishing  sarcomas  from  other  processes 
in  which  fully  developed  tissue  is  being  formed.  They  must  be  differ- 
entiated from  inflammatory  swellings,  which  may  be  due,  as  ordinarily, 
to  a  pyogenic  microbe;  or  to  one  of  the  specific  inflammatory  processes, 
namel}^  the  granulomas.  Some  of  the  hypertrophic  processes  may 
in  rare  cases  suggest  sarcomas.  Inflammatory  processes  present  unripe 
connective  tissue,  and  a  judgment  must  be  formed  as  to  whether  it 
has  the  potency  to  form  adult  tissue.  In  general,  recognition  of  a  growth 
as  a  variety  of  connective-tissue  tumor  depends  upon  the  demonstra- 


M/ckoscff/'/c  i)/./(;\()S/s  (J J   s.iRi.oM.i  121 

rion  ot  iiirnit  lliil.ii  hhnls.  I  Ins  m;iv  l)i- (lilhiiili  id  some  instances,  and 
tuiiiKiith  spriitu-  st.nns  nia\  he  ncicssaiv  m  okKi  to  {Icrc-rminc  it. 
( )t  rlusf,  \an  ( lie-son's  stain  is  ilu  most  (.oiu  tnunt  and  .\l;ill()iy's  the 
most  iHuunr;  in  tact,  with  the  hitici  it  is  iaicl\  iinpossihh-  to  detei- 
niiiu'  this  point.  Mu'  method  of  ixiuihii;;  oi  shaking  out  the  cells 
emi')lo\cd  h\  main  pathologists  is  inon  dehnitc-  hut  less  convenient. 
\\  hen  the  connecti\e-tissue  nature  of  the  growth  has  been  determined 
it  becomes  necessary  to  differentiate  it  from  otiur  processes  attended 
by  connective-tissue  proliferation.  I  his  is  iisiiall\  possible  by  con- 
siderin<i;  several  deHnite  points  as  follows: 

{a)  The  Size  of  the  Cell.  In  sarcoma  the  cells  are  more  uniform  than 
in  inflamniator\'  processes.  In  the  latter,  the  fibroblasts,  which  often 
very  closely  resemble  sarcoma  cells,  are  interminji;led  with  plasma  cells 
and  the  various  leukocytes.  The  sarcoma  cells,  on  the  other  hand,  are 
less  uniform  in  size  than  the  fully  developed  connecti\e-tissue  cells. 
In  many  sarcomas  the  size  of  the  cells  may  vary  ji;reatly,  but  they  are 
of  the  same  character. 

(b)  The  Bloodvessels. — The  bloodvessels  in  inflammatory  processes 
are  usually  more  numerous  than  in  any  tumor.  In  very  young  granu- 
lation tissue  the  cells  ma}^  bear  the  same  intimate  relation  to  the 
bloodvessels  as  in  sarcoma,  but  in  the  more  chrome  processes  there 
is  distinct  connective-tissue  sheath  about  the  vessel  walls. 

{c)  Fibrin. — In  inflammatory  processes  fibrin  clumps  and  bundles 
can  usually  be  demonstrated  by  Weigert's  stain,  but  they  are  absent 
from  sarcoma. 

id)  Deviation  in  Cell  Division. — The  presence  of  an  abundance 
of  mitotic  figures,  particularly'  when  they  are  irregular,  speaks  for 
sarcoma. 

{e)  The  Border  of  the  Tumor. — Even  in  infiltrating  sarcoma  the  border 
of  the  tumor  is  more  sharpl}'  defined  than  in  inflammatory  processes. 
By  microscopic  examination  this  is  even  more  clearly  marked  than  by 
macroscopic  observation. 

(/)  Evidence  of  Specific  Processes. — Often  the  findings  of  a  microbic 
cause  of  the  process  clears  up  a  doubtful  case,  particularl)'  in  tuber- 
culosis and  syphilis.  The  unit  lesion  in  these  diseases  ma}',  even  when 
the  specific  organism  cannot  be  demonstrated  give  nearly  certain 
evidence,  such  as  giant  cells  in  tuberculosis  and  gummas  in  s\'philis. 

When  all  the  resources  of  differentiation  have  been  exhausted  it 
must  be  recognized  that  there  are  no  positive  signs  of  sarcoma.  It 
becomes  necessar\'  to  resort  to  other  evidence  than  that  which  the 
microscopic  evidence  gives  us,  such  as  the  macroscopic  appearance 
and  the  history  of  the  growth.  It  is  particularly  necessary  to  remember 
special  instances  in  which  sarcoma  may  be  very  closely  imitated,  and 


122  SARCOMA 

in  which  the  source  of  the  tissue  and  the  circumstances  of  its  removal 
alone  can  save  us  from  error.  A  pronounced  example  of  this  may  be 
seen  in  certain  proliferative  processes  in  the  endometrium  in  which 
the  interstitial  tissue  is  made  up  of  large  uniform  cells  which  bear  a 
close  relation  to  the  bloodvessels.  In  certain  congenital  conditions 
cell  masses  closely  resembling  sarcomas  are  frequenth'  observed.  In 
hj'perplastic  processes  in  the  digestive  tract  sarcoma  ma}^  be  closely 
imitated. 

The  safe  rule,  therefore,  in  the  diagnosis  of  sarcoma  is  to  demand 
a  knowledge  of  the  source  of  the  material  and  the  history  of  the 
growth. 

Prognosis. — The  prognosis  of  all  sarcomas  is  doubtful.  In  the  small- 
celled,  rapidly  growing  types,  and  m  the  melanotic,  it  is  absolutely 
bad;  in  the  fibrosarcoma,  fairl}^  good;  and  in  the  giant-celled  types, 
favorable.  Each  case  requires  a  separate  estimate  based  on  the  exact 
nature  of  the  tumor.  When  metastasis  or  regional  extension  has  taken 
place  the  outlook  is  hopeless.  Man}'  of  the  sarcomas  which  have  given 
favorable  histories  in  the  past  are  known  from  our  present  knowledge 
to  belong  to  the  endotheliomas  or  to  the  mixed  tumors,  and,  therefore, 
the  general  prognosis  of  sarcoma  requires  revision  m  the  light  of  this 
newer  knowledge.  The  occurrence  of  leukocytosis  and  a  rise  of  tem- 
perature discloses  the  case  as  hopeless. 

Treatment. — Constitutional. — (a)  Drug^. — The  onh'  drug  capable 
of  exercising  any  influence  upon  the  growth  of  sarcoma  is  arsenic.  Its 
influence  on  any  but  the  lymphoid  type  is  problematical,  but  one  may 
be  glad  to  have  even  so  unpromising  a  remed}'  in  otherwise  hopeless 
cases.  The  form  of  drug  given  is  unimportant  and  the  dosage  should 
be  kept  within  eas}^  tolerance  of  the  patient.  In  the  lymphatic  type 
some  improvement  appears  at  times,  but  these  are  cases  in  which  the 
diagnosis  is  not  always  clear.  On  the  whole,  little  more  can  be  said 
for  the  drug  than  that  it  is  a  legitimate  placebo.  For  the  value  of 
methylene  blue  there  is  even  less  evidence.  It  is  sometimes  given  in 
2  to  5  grain  doses  three  times  a  da}^ 

ih)  Sera. — In  1891  Fehleisen  discovered  that  a  sarcoma  in  which 
erysipelas  became  accidentally  implanted  decreased  rapidly  in  size. 
Following  this  accident  numerous  investigators  infected  patients  who 
were  victims  of  inoperable  sarcoma  with  erysipelas,  in  the  hope  of 
producing  a  favorable  influence  upon  the  growth  of  the  tumor.  Diffi- 
culties were  encountered  in  diff^erent  directions.  In  many  patients  it 
was  impossible  to  produce  an  infection,  and  of  those  infected  many 
died. 

Based  on  these  experiences  and  the  researches  of  Roger,  which 
demonstrated    that   streptococcus   is   more   virulent   in   the   presence   of 


TRE.ITMESr  or  S.IRCOM.I  VIW 

Bacillus  prodij^iosiis,  C'()K\  '  has  inoImcI  a  line  of  treatment  worth)'  of 
attenrion.  H\'  the  iist-  ot  imxtil  toxins  of  rlust-  or^anisnis  he  has  been 
able  ro  piodiui-  nsults  not  obtaniabU-  b\  the  streptococcus  alone. 
I  hi  Hanlhis  prodi^iosus  itself  seems  to  ha\i-  cuian\c-  action,  on  do^ 
sarcoma  at  least.  I  he  action,  according  to  the  researches  of  1  rac\',- 
is  brought  about  by  the  production  of  leukocytosis  and  coagulation 
necrosis. 

C\)le\  has  usfd  these  mixed  toxins  in  400  cases  witii  but  3  deaths, 
and  42  successful  cases,  approximatinji;  10  per  cent,  of  cures;  2S  of  these 
ha\e  remained  well  more  than  three  years.  Considering  the  absolutely 
fatal  nature  of  the  disease  under  other  treatments,  these  statistics  make 
the  treatment  well  worth)  of  trial.  It  must  be  added  that  in  other 
hands  the  remed\  has  not  been  as  successful  as  in  the  hands  of  the 
oriiiinator.  The  methods  of  production  and  the  use  of  toxins  cannot 
be  described  here  with  the  necessary  detail,  and  the  reader  is  referred 
to  the  oriiiinal  papers  of  Dr.  Colew' 

Physical  Measures. — The  use  of  the  .v-rays  has  been  confined  chiefl)', 
as  it  should  be,  to  the  treatment  of  inoperable  cases. ^  In  these  a  reduc- 
tion in  the  size  of  the  tumor  has  resulted  and  sometimes  a  marked 
amelioration  of  the  symptoms.  It  is  unlikely  that  cure  has  resulted 
in  real  sarcoma.  In  some  cases  of  rapidly  o;rowing  sarcomas  of  the 
extremities,  where  amputation  is  possible  but  a  recurrence  is  certain, 
the  surgeon  has  his  choice,  and  his  selection  will  depend  somewhat  upon 
the  availability  of  the  services  of  a  competent  Rontgenologist. 

Operative. — The  old  rule  for  the  operative  treatment  of  sarcoma  was 
to  perform  a  most  radical  operation  at  the  earliest  moment:  in  sarcomas 
of  the  extremities,  for  instance,  amputation  at  least  as  high  as  the  next 
proximal  joint  was  the  rule.  But  in  the  last  few  years,  chiefly  through 
the  efforts  of  Bloodgood,  much  clearer  indications  for  treatment  have 
been  outlined,  depending  upon  the  different  degrees  of  malignancy  of 
the  various  t\'pes  of  sarcoma.  The  relatively"  benign  t^pes  permit  of 
conservative  operation.  It  is  particularly'  the  giant-celled  variety  that 
lends  itself  to  local  excision;  the  removal  of  the  tumor,  together  with  an 
area  of  the  surrounding  tissue,  leads  uniformly  to  a  cure,  as  is  shown 
by  the  statistics  of  Bloodgood.  Even  those  characterized  b}'  persistent 
local  recurrence  are  often  finally  cured  b\'  repeated  operations.  On  the 
other  hand,  even  the  most  radical  operations  performed  very  early  failed 
in  effecting  a  cure  in  certain  types,  such  as  the  small-celled  growths  of 
the  fascia  and  the  melanotic  types  in  which  local  recurrence  or  metastasis 

^  Amer.  Jour.  Med.  Sci.,  1893,  cv,  487;  Med.  Record,  1907,  ixxii,  129;  Proceedings  of 
tiie  Royal  Society  of  Medicine,  John  Bales'  Sons,  London,  1909. 

-Jour.  Amer.  Med.  Research,  1907,  xvi,  307.  ^  Loc.  cit. 

^  Phaler,  New  ^'ork  Med.  Jour.,  1907,  Ixxxvi,  11 53. 


124  SARCOMA 

uniforml}^  occurs.  Thus  in  68  cases  collected  by  Butlm  but  one  was 
alive  after  three  years. 

To  the  extremely  bad  ultimate  results  must  be  added  the  risk  of  the 
primar}^  operation,  which  in  the  extensive  amputations  required  is  con- 
siderable. It  is  undoubtedly  true  that  so  far  as  the  results  of  the  treat- 
ment go  sarcomas  may  be  divided  into  those  which  are  cured  by  local 
excision  and  those  not  curable  by  the  most  radical  operation.  In  the 
extensive  sarcomas  operation  is  but  a  palliative  measure,  and  it  must 
be  decided  for  each  case  whether  the  risk  should  be  undertaken  in  order 
to  relieve  the  patient  for  a  time.  The  location  of  the  tumor,  the 
condition  of  the  patient,  and  the  rate  of  growth  must  weigh  in  the 
decision.  Amputation  fills  the  patient's  mind  with  hope  of  cure  and 
often  makes  his  remaining  days  more  useful. 

It  is  impossible  to  decide  if  there  are  border-line  cases  in  which  ampu- 
tation will  cure  when  local  excision  is  impossible.  Giant-celled  tumors 
may  be  so  extensive  that  the  bone  is  destroyed  and  pathological  fracture 
takes  place.  In  these  an  amputation  or  plastic  bone  operation  is  needed. 
There  are  too  many  uncertainties  in  diagnosis  in  reported  cases  of 
permanent  cures  of  the  more  malignant  types  to  permit  of  judgment. 
Certain  it  is  that  many  limbs  are  amputated  which  might  be  saved 
by  local  excision  of  the  tumor.  The  burden  of  proof  lies  upon  those 
who  obtain  permanent  cures  by  amputation  to  show  that  cure  was  not 
possible  by  local  excision. 


C"  il  A  1'   I    K  k     X 
Mll/niM.K    M^KI.OMAS 

General  Conception.  1  lu-  tcnn  nuilnplc  "  iii\  tlonia"  was  hrsr  applied 
b\'  Rustizk\'  to  multiple  tumors  wliicli  occur  simultaneousl)'  in  the 
marrow  of  bones.  Ihey  are  rare  tumors;  probably  not  more  than  30 
are  to  be  found  in  the  literature.  ihey  occur  usually  in  advanced 
\"ears  and  most  frequent!)"  in  males.  1  hey  usually  run  their  course 
in  about  two  years.  Clinically,  severe  pain,  progressive  emaciation, 
and  the  occurrence  of  Bence-Jones  albumm  m  the  urine  are  the  char- 
acteristic features.  The  tumors  both  by  the  course  of  their  develop- 
ment and  by  their  histological  structure  indicate  that  the}'  belong,  as 
\  irchow  believed,  to  a  type  higher  than  sarcoma,  which  they  resemble 
somewhat  histologically.  In  their  course  they  resemble  the  myeloid 
sarcomas,  to  which  they  are  probabl}'  most  closely  related,  since  they 
but  rarel}'  produce  metastases,  though  Tschistowitsch-  has  shown  that 
these  ma\'  occur.  They  displace  the  bone  and  give  rise  to  pathological 
fractures.  Their  histological  structure  and  their  effect  upon  the  general 
constitution  suggest  also  some  relation  to  lymphosarcoma  and  myelo- 
genous leukemia.  Winkler,-^  with  much  show  of  reason,  proposes  a 
separate  classification  for  these  tumors,  and  compares  them  m  their 
limited  capacity'  of  growth  wqth  the  gliomas. 

Macroscopic  Structure. — Multiple  myelomas  are  red,  soft,  and  pulta- 
ceous,  with  occasional  grayish  areas  which  are  more  firm.  L  suall}"  the 
borders  are  not  sharply  defined,  and  in  cases  where  a  line  of  demarca- 
tion exists  betw^een  the  marrow  and  the  tumor,  \\  .  G.  McCallum^ 
found  that  tumor  cells  extend  beyond  the  apparent  capsule. 

Microscopic  Structure. — Round  cells  arranged  loosely  in  a  definite 
reticulum  characterize  these  tumors.  The  cells  vary  in  size,  but  are 
usualh'  large,  15  to  20  microns  in  diameter,  with  a  prominent  vesicular 
nucleus  and  prominent  nucleolus.  Wright'  regarded  them  as  plasma 
cells,  and  proposed  the  term  plasmoma.  McCallum,  after  a  careful 
histological  study   of  a    case,    regarded    them    as    related    more   closely 

^  Deutsch.  Ztschr.  f.  Chir.,  1873,  ill,  162. 

-  Virchow's  Arch.  f.  path.  Anat.,  1909,  cxcvii,  112. 

^  Ibid.,  1900,  clxi,  252. 

■•  Jour.  Exper.  Aled.,  1901,  vi,  ^} 

•'Johns  Hopkins  Hosp.  Rep.,  1900,  ix,  359. 


126  MULTIPLE  MYELOMAS 

to  the  myelon^tes,  being  derived  from  their  large  non-granular  fore- 
runners. Christian^  describes  a  number  of  kinds  of  cells,  and  it  seems 
certain  that  there  may  be  various  histological  types.  Tschistowitsch 
divides  them  into  four  classes — lymphocytomas,  myelomas,  plasmomas, 
and  erythrocytomas. 

Diagnosis. — The  tumors  can  be  easily  distinguished  from  the  myeloid 
sarcomas  by  the  uniformity  of  the  cells,  the  spindle  and  giant  cells 
of  the  sarcomas  being  always  absent.  The  local  hyperplasias  some- 
times accompanying  leukemia  are  most  difficult  to  distinguish  from 
them.  That  there  is  no  sharp  dividing  line  histologically  seems  possible 
from  the  case  reported  by  King,^  in  which  there  were  a  large  number 
of  megaloblasts.  Differentiation  between  the  two  conditions  would 
depend  upon  the  discovery  of  the  Bence-Jones  albumin.  Jellinek^ 
refers  to  the  similarity  between  multiple  myeloma  and  the  bone  meta- 
stases of  endotheliomas  and  hypernephromas.  The  discovery  of  a 
primary  tumor  and  the  absence  of  the  Bence-Jones  albumin  are  char- 
acteristic of  the  latter.  In  some  cases  the  A:-rays  may  be  required 
to  show  multiple  myelomas  in  bone  when  they  are  not  evident  by 
ordinary  means. 

^  Boston  Med.  and  Surg.  Jour.,  1908,  clviii,  617. 

^  Jour.  Amer.  Med.  Assoc,  191 1,  Ivi,  1092. 

^  Virchow's  Arch.  f.  path.  Anat.,  1904,  clxxvii,  96. 


r  II  A  1'  r  !•:  k    x  i 

ANGIOMAS 

Definition  and  Classification.  I  luK  i  tin  tciin  ";inui()m;i"  is  grouped 
;i  \:irirr\'  of  riiniors  irsulniiu  fioni  rlif  luw  toinintKni  ol  xtsscls.  I  wo 
t\'pes  are  rc'C()<;ni/.ccl,  tlu'  luiiian<;i()iiias,  ansiiii;  from  hlootlNcsscis,  and 
the  much  K-ss  fitHiiunt  1\  niphaii<i;i()mas,  aiismii  from  l\-mph  vessels. 
Ihe  hemangiomas  are  not  a  well-defined  group  ot  rumors,  and  cxcn 
the  most  t\  pical  are  not  made  up  entirel\'  of  ne\\l\  toiined  \essels, 
hut  parth  h\  a  dilatation  of  vessels  already  present,  in  the  niajorit\' 
of  angiomas  the  new  formation  consists  in  growth  m  length  rather 
than  in  production  of  new  vessels.  Most  congenital  hemangiomas  are, 
stricth'  speaking,  developmental  anomalies  rather  than  true  tumors  in 
the  general  acceptance  of  the  term.  In  other  instances,  our  mforma- 
tion  is  not  sufficient  to  justify-  an  opinion  as  to  their  origin,  as,  for 
instance,  those  occurring  in  the  internal  organs.  It  is  generally  agreed 
that  those  tumors  which  result  from  a  dilatation  of  preformed  vessels 
should  not  be  included  in  the  group  of  angiomas.  These  include  the 
varicosities  and  aneurysms.  The  former  in  some  instances,  as  m  hemor- 
rhoids, are  attended  by  perivascular  reaction  with  production  of  fibrous 
tissue,  and  thus  become  veritable  tumors.  Similar  conditions  are 
observed  in  the  labia.  The  aneurAsmal  varices,  frequently  progressive 
in  character  and  often  having  the  clinical  significance  of  true  tumors, 
are  likewise  excluded  from  consideration,  though  the  evidence  of  newly 
formed  vessels  is  sometimes  ver}'  suggestive. 

HEMANGIOMAS 

Classification. — This  type  is  usuall}"  divided  into  two  classes,  simple 
and  cavernous  angiomas. 

Simple  Angiomas. — These  are  flat  tumors  composed  of  capillaries,  and 
project  little,  if  any,  above  the  surface  of  the  skin.  The\-  are  formed 
b}'  the  dilatation  of  preexisting  vessels,  with  little  or  no  new  forma- 
tion (Fig.  65).  They  usually  occur  in  the  skin,  are  congenital,  and 
usualh"  keep  pace  in  growth  with  the  growth  of  the  child.  The  vessel 
walls  are  frequently  devoid  of  muscular  coats.  The  endothelium  is 
normal  but  the  intervascular  connective  tissue  may  be  somewhat 
mcreased. 


128 


ANGIOMAS 
Fig.  65 


b  - 


C- 


"^■iyffi't 


■l^m'a^on'i 


Simple  deep-seated  angioma  of  skin:  a,  epidermis;  b,  connective  tissue; 

c,  bloodvessels. 

Fig.  66 


\l       '  ' 


--^^X         N  , 


» V  ^    <t  ?i  -^        iS*'?  ,!f 


J^ 


Hypertrophic  angioma  of  leg,  showing  tumor  with  enlarged  bloodvessels, 
epidermis,  and  corium. 


III.MIM'.IOM.IS 


129 


riu-    In  pel  I  lopliu-    .iiiL;,i<)m;is    of    /u-^Ki     ww    \v\\     c\nsc\\     irhitcd     to 
the    sImpK-    iiniiioiiKis,    Inn    pnstiit    more    i  \  ultiuc    oi    ;kiii;i1    \;isi.iil:ii 


V\c..  67 


/; 


.'.'■     <'   '  •! 


.^/••■.-■■■'.;' 


a 


Angioma:  a,  laroe  caverns  tilled  with  blood  lined  with  simple  endothelium; 

b,  connective  tissue. 

Fig.  68 


llji>...J,'..i. '•••.".»■'  ■    r  ■'"'■-.      v       .■  °J  "■•.     .'    '  ■•       i       ' 


130  ANGIOMAS 

growth.  They  usually  project  from  the  surface  (Fig.  66).  The  vessel 
walls  are  often  imperfect,  sometimes  bemg  mere  connective-tissue 
tubules  lined  with  endothelium  (Fig.  67),  which  when  the  blood  spaces 
are  empty  becomes  contracted  and  gives  the  tumor  the  appearance 
of  adenoma  of  the  sweat  glands  (Fig.  68).  In  some  instances  the 
endothelium  shows  such  activity  of  growth  as  to  resemble  the  endo- 

FlG.  69 


}ifsp  "'\- 


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•  •  . '■' '"■■''T/"'-V?ii-3'' v.'^^v;''^i'---.*-  ^'i'*.'.*7?«S'fti:i^;?.(    "-'tS?^'^'  -'^^r^' 

•»f,/  v.,     ■■''-  "•  -        ,      ■  ■     •^•y-t^i    '•"^%,    _  ,    »;" 


Hemangioma,  with  proliferation  of  its  walls:     a,  blood  spaces;  b,  proliferated 
endothelium;  c,  connective  tissue. 

,theliomas    (Fig.   69).      On   the  other  hand,   the  connective   tissue   may 
be  so  abundant  and  cellular  as  to  resemble  the  sarcomas  (Fig.  70). 

Cavernous  Angiomas, — In  this  class,  as  the  name  indicates,  the  blood 
spaces  are  large  compared  with  angioma  simplex.  Its  most  frequent 
location  is  the  skin  and  liver,  less  frequently  in  other  internal  organs. 
The  walls  of  the  sinuses  are  usually  thin,  devoid  of  musculature,  and 


c./rr.kXfJi  s   im.iom.is 


i:;i 


liiKtl  by  a  flat  tiulot  luliiim  '  I' i<;.  71).  1"  ii-(]iicni  l\  (.on^cnital,  tlK\-  \\\\i\ 
remain  statioiiaiN  ,  l>iit  at  tiiius  rluit-  is  a  ^i<)\stli  of  the  vessels  in  length 
wimh    tiia\    Infill   Mi(iiliiil\    ami   cause   tlu-   tumor   to  assume   im|)oit;mr 


I'k;.  70 


o      til    '-- J/i.J"        '  ^  > 


1^  '■       ^    '- 


t 


Angioma  with  cellular  connecrne  tissue 


Fig.  71 


/yo'^^'.r^i! 


;i7?;'Q^- 


v 


c 


avernom 


a  of  li 


132  .  ANGIOMAS 

proportions.  The  connective  tissue  likewise  may  become  active  and 
cause  varicosities  b}'  contracting  the  lumen  of  the  vessels  at  certain 
points.     This  tA'pe  is  not  attended  by  a  development  of  endothelium. 

Aneurysmal  Varices. — This  condition,  which  is  generalh'  excluded  from 
the  angiomas,  has  much  in  common  with  the  cavernous  angiomas. 
It  is  formed  of  dilated  vessels,  and  frequentl}'  increases  rapidly  in  size, 
exhibiting  a  progressive  dilatation  as  well  as  an  increase  in  length  and 
a  connective-tissue  formation.     It  is  therefore  a  veritable  tumor. 

Course. — Angiomas  are  distincth'  benign  tumors.  Their  impor- 
tance consists  m  the  resulting  deformities  and  occasional  rupture  from 
trauma.  They  often  disappear  spontaneously.  The  aneurysmal  varices 
have  a  disposition  to  extend  and  destroy  the  surrounding  tissue  by 
pressure. 

Diagnosis. — Macroscopic. — The  simple  angiomas  are  easily  recog- 
nized as  livid  spots  in  the  skin  or  mucous  membrane.  The}"  can  be 
confused  onh'  with  petechia,  from  which  the}-  are  easil}'  differentiated, 
b}'  noting  that  the  angiomas  readil}-  disappear  on  pressure  onl}"  to 
return  when  the  pressure  is  removed.  The  h}'pertrophic  t}'pe  appear 
usuall}'  as  elevations  above  the  surface,  resembling  warts,  but  are  softer, 
redder  in  color,  and  are  reducible  b}'  pressure.  The  cavernous  angiomas 
appear  as  livid  elevated  tumors,  soft  to  the  touch,  disappearing  on 
pressure,  and  becoming  more  tense  with  increased  blood  pressure. 

Microscopic. — The  h}-pertrophic  t}'pe,  particularl}'  when  m  course 
of  active  development,  may  be  confused  with  sudorific  adenomas. 
Lsuall}'  at  some  point  m  the  periphery  of  the  angioma  a  definite 
lumen  containing  blood  can  be  discovered.  This,  together  with  the 
fact  that  in  adenomas  a  basement  membrane  is  present,  obviates  any 
error.  In  the  cavernous  t}'pe  the  large  endothelial-lined  spaces  filled 
with  blood  are  unmistakable. 

In  all  t}'pes  when  there  is  an  active  proliferation  of  endothelium 
the  question  of  the  presence  of  endothelioma  arises.  Usuall}',  if  there 
is  evidence  of  endothelial  proliferation  m  angiomas,  it  is  in  the  nature 
of  an  h}'pertroph}',  and  there  is  no  change  in  cell  type,  while  in  vascular 
endotheliomas  there  is  a  change  in  the  form  of  the  cells  most  remote 
from  the  lumen  of  the  vessel  or  from  the  intima.  In  those  instances  in 
which  there  is  an  active  proliferation  of  connective  tissue  between  the 
vessels  the  cells  likewise  are  of  uniform  size  as  distinguished  from  the 
variation  in  cell  form  m  the  slowly  growing  sarcomas.  In  all  instances 
the  form,  situation,  and  life  history  of  the  tumor  must  be  taken  into 
consideration.  The  disposition  to  append  the  appellation  "angio"  to 
every  sarcoma  possessed  of  an  abundant  blood  suppl}'  has  caused 
unnecessar\'   confusion. 


i.r.\ir//.i\(:/o.\i,is  ]:v.', 

Treatment.  Since  angiomas  ait.-  iisuallv  ot  no  more  serious  conse- 
(|iifncf  than  as  a  ckformit\  ,  tluir  imporraiKc  and  treatment  depend 
on  the  location.  In  general,  it  may  lie  said  that  the  cavernous  types, 
it  localized  and  suitahh  siruati-d,  may  he  excised  m  order  to  pre\ent 
suhsecjuent  rapid  growth.  If  situated  on  exposed  parts,  electrolysis  or 
segmental  ligation  will  ha\e  preference  (see   fumors  of  the  Face). 


LYMPHANGIOMAS 

In  the  l\  niphatic  tumors  there  is  usually  less  evidence  ot  newly 
formed  vessels  than  in  the  angiomas.  fhey  are  usuall\'  congenital, 
resulting  perhaps  from  maldevelopment  of  the  lymph  channels.  In 
some  instances  there  is  probably  development  ot  new  sinuses  or  at 
least  the  dilatation  of  preformed  channels.  The  spaces  vary  in  size 
and  are  lined  by  a  thin  endothelium  surrounded  by  a  thin  wall  of  con- 
nective tissue   (Fig.   72).      In   rare  instances,  as  in   macroglossia,   there 

Fig.  72 


— o  •  '-^  V  »'  'KV'  I 


\ 


Lymphangioma  of  the  face,  showmg  lymph  spaces,  interstitial  tissue,  and  section  of 

sweat  gland. 

is  an  infIammator\"  increase  of  the  connective  tissue.  The  relations 
between  connective  tissue  and  lymph  spaces  is  not  clear.  Attempts 
have  been  made  to  divide  the  lymphangiomas  into  classes  similar  to  the 
hemangiomas.  Simple  superficial  lymphangiomas  correspond  closeh' 
to  like  tumors  of  the  capillaries,  but  usually  the  lymph  spaces  corre- 
spond to  the  cavernous  angiomas,  but  often  exceed  these  greatly  in  size. 
In  some  situations  (tongue)  the  new  development  of  lymph  spaces 
unmistakably  corresponds  with  the  aneurysmal  varices. 


134  ANGIOMAS 

Course. — Lymphangiomas  are  of  importance  because  of  their  size 
and  situation  and  because  of  the  possibihty  of  rupture  in  the  large 
cystic  type  with  the  ensuing  exhaustive  drainage,  and  of  gradual  exten- 
sion in  the  proliferative  type. 

Diagnosis. — Macroscopic. — The  soft  transparent  lobulated  tumor  is 
usually  sufficient  for  recognition.  They  are  sometimes  simulated  by 
other  cysts.  When  situated  so  deeply  that  the  color  of  the  contents 
cannot  be  made  out,  they  are  differentiated  from  hemangiomas  by 
their  failure  to  be  reduced  by  pressure.  Their  most  frequent  site  is 
in  the  cheek  or  about  the  neck.  In  cases  of  doubt  aspiration  may  be 
practised. 

Microscopic. — The  identification  of  cavities  lined  by  endothelium 
is  strongly  suggestive.  The  nature  of  the  contained  fluid  is  the  only 
certain  diagnostic  point. 

Treatment. — Excision  should  be  practised  whenever  possible.  It  is 
frequently  the  case  that  because  of  their  situation,  their  extent,  and 
the  age  of  the  patient,  excision  is  impracticable.  Drainage  and  injec- 
tion of  irritating  substances  must  then  be  resorted  to,  or  operation 
must  be  delayed  to  a  more  favorable  age  (see  Lymphangioma  of  the 
Neck). 


c  w  \v  r  K  k    X  I  I 

KNDOI  IIKI.IOMAS     CI  lOLKS  TKA  lOMAS 

ENDOTHELIOMAS' 

Conception  and  Dehnition.  A  conception  ot  the  nature  ot  the  tuniois 
heretofore  considered  was  easily  gained  by  comparing  the  pathological 
anatom\'  of  the  tumor  with  the  normal  tissue  from  which  it  sprang. 
This  was  eas\'  because  the  normal  tissue  was  well  characterized  and 
its  peculiar  features,  both  histological  and  pathological,  were  uncjues- 
tioned.  W  ith  the  endotheliomas  the  characterization  is  more  difficult, 
not  only  because  of  their  great  variation  in  structure  but  also  because 
the  nature  of  the  mother  tissue,  the  endothelial  cells,  is  still  a  matter 
of  dispute. 

We  are  compelled,  therefore,  to  preface  the  discussion  of  the  pathology 
of  endotheliomas  b}-  a  few  remarks  on  the  nature  of  endothehum.  The 
term  was  first  used  b\-  His  to  apply  to  the  fiat  cells  lining  the  cavities, 
including  the  blood  and  l\-mph  vessels  as  well  as  the  joint  surfaces. 
Later  anatomists  have  sought  to  limit  the  term  to  those  cells  which 
correspond  morphologically  to  the  conception  of  His  but  have  their 
origin  in  the  mesenchyme.  This  excludes  those  lining  the  pleuro- 
peritoneal  cavity.  Other  anatomists  have  sought  to  abandon  the  term 
entirely.  More  recenth'  Borst  and  Ribbert  have  declared  themselves  in 
favor  of  retaining  the  original  conception  of  His.  There  is  no  reason 
in  patholog}',  Borst  declares,  to  distinguish  between  the  cells  lining 
the  vessels  and  those  lining  the  serous  cavities. 

Histologicall)',  the  endothelial  cells  are  flat,  with  large  oval  nuclei 
and  prominent  nucleoli.  The  protoplasm  is  abundant  and  clear.  Phy- 
siologically, the  -endothelial  cells  pla\-  a  prominent  part  in  nutrition 
(Heidenhain),  not  only  filtering  the  passing  fluid,  but  altering  its  con- 
sistenc\'  also.  In  pathological  conditions  the  endothelial  cells  have  a 
ver\-  definite  action.  Under  irritation  they  swell  and  become  cuboidal 
and  even  columnar.  In  function,  the\-  stand  midwa\-  between  the 
epithelium    and    connective    tissue,    assuming    secretory    functions    like 

'  For  literature  see  v.  Volkmann,  Deutsch.  Zeits.  f.  Chir.,  1895,  xli,  i;  Marchand, 
Verh.  d.  Deutsch.  path.  Gesellsch.,  1900,  ii,  38;  and  Krompecher,  Beitr.  path.  .Anat., 
1905,  xxxvii,  28. 


136  ENDOTHELIOMAS— CHOLESTEATOMAS 

the  former  and  playing  an  active  part  in  the  production  of  the  latter. 
Much  useless  controversy  has  been  waged  as  to  whether  endothelium 
resembles  epithehum  more  than  it  resembles  connective  tissue,  and  the 
discussion  was  naturall}^  carried  into  the  classification  of  endothelial 
tumors.  As  a  matter  of  fact,  endothelium  is  as  well  individualized 
in  structure  and  function  as  either  of  these  tissues,  and  is  quite  as  well 
worthy  of  a  place  among  the  primary  tissues.  Accordingly,  the  term 
endothelium  should  suggest  a  definite  type  of  tissue  and  not  a  sub- 
division of  any  other  tissue.  The  same  may  be  said  of  the  tumors 
originating  from  it.  Standing  midway  between  epithelium  and  con- 
nective tissue,  the  tumors  arising  from  it  may  be  expected  to  maintain 
a  corresponding  relationship  to  epithelial  and  connective-tissue  tumors. 
The  deviation  in  structure  from  either  of  these  is  less  than  they  are 
from  each  other.  Naturally,  the  resemblance  to  either  the  carcinomas 
or  the  sarcomas  becomes  closer  when  one  or  the  other  of  the  normal 
functions  is  emphasized.  Thus  if  for  any  reason  the  connective-tissue 
forming  properties  are  brought  to  the  foreground,  it  will  not  be  sur- 
prising if  the  sarcoma  should  be  closely  imitated. 

It  is  these  peculiarities  which  make  questions  of  differentiation  so 
difficult.  The  problem  has  needlessly  been  made  more  complex  by  the 
addition  to  the  endotheliomas  of  groups  of  tumors  bearing  no  genetic 
relation  and  but  little  morphological  resemblance  to  them.  These 
groups  are  the  mixed  tumors,  the  cholesteatomas,  and  the  carotid 
tumors.  Some  investigators  (Henke)  are  disposed  to  class  certain 
nevi  with  the  endotheliomas.  This  has  a  certain  justification  in  struc- 
ture; but  the  cells  of  nevi  are  embryonal  and  have  not  undergone 
differentiation  into  cells  possessed  of  a  higher  function,  as  have  endo- 
thelial cells.  When  nevi  undergo  active  proliferation  they  give  rise 
to  cells  of  a  very  low  order,  as  is  manifest  by  the  great  malignancy  of 
the  tumors  they  form.  It  will  be  an  aid  to  clearness  to  retain  such 
tumors  in  a  separate  class  until  their  nature  is  understood. 

Endotheliomas  may,  therefore,  be  defined  as  tumors  which  develop 
from  the  cells  lining  the  blood  and  lymph  vessels  and  the  lymph  spaces. 
It  is  not  necessary  to  include  the  cells  lining  the  serous  cavities,  because 
they  have  not  given  rise  to  tumors.  They  are  characterized  by  pro- 
hferation  of  the  endothehal  cells  and  invasion  of  the  surrounding  tissue. 

Classification. — Much  aid  in  the  classification  of  the  endotheliomas 
could  be  obtained  if  the  life  history  of  the  tumors  were  considered. 
The  entire  problem  heretofore  has  been  considered  from  a  purely 
morphological  standpoint.  Unquestionably  a  tumor  cell  is  of  interest 
quite  as  much  because  of  what  it  does  as  because  of  its  origin,  form, 
and  structure.  Pathologists  admit  that  the  nature  of  a  single  cell 
cannot  be  determined   except  by  its  relation  to  other  cells  and  to  the 


EMxyriii.i.KjM.is  \M 

surrounding  tissue.  I  Ins  is  an  admission  that  the  chief  evidence  for 
determining  the  nature  of  a  cell  is  ohtamed  from  its  morphogenesis. 
It  would  seem  that  if  the  entire  life  histor\'  of  tumors  were  considered 
as  re\ealecl  in  tin-  clinical  lnst()i\  ,  much  aid  vsould  he  gi\en  in  the  classiH- 
cations  of  tumors.  In  no  class  ot  tumors  d(K*s  this  seem  as  important 
as  in  the  eiulotheliomas.  All  types  have  in  common  the  characteristic 
cells,  aiul  their  recognition  depends  upon  the  discovery  of  the  situation, 
usualh  at  the  periphery,  where  the  transition  can  be  made  out.  I  he 
cells  springing  from  the  typical  situations  extend  into  the  connective- 
tissue  clefts.  I  heir  nature  tits  them  for  lining  spaces,  and  narrow  columns 
can  often  in-  made  out  extending  among  the  connectue-tissue  hhrils. 
I'his  close  relationship  is  retained  in  their  subsequent  development, 
and  the\'  are  usually  in  close  contact  with  the  connective  tissue,  t  re- 
quenth'  Hbrils  may  be  demonstrated  extending  between  the  cells  of 
endotheliomas,  the  ease  with  which  they  can  be  shown  depending 
upon  the  nature  of  the  tumor.  The  nearer  the  approach  to  a  sarcoma 
t\pe  the  more  likely  will  such  demonstration  be  possible. 

There  are  no  well-defined  groups  either  from  arrangement  of  cells, 
as  in  cancer,  or  from  types  of  cells,  as  in  sarcoma;  but  for  convenience 
the\-  may  be  divided  according  to  the  situations  of  the  cells  from  which 
they  spring.  These  sources  are  the  cells  lining  the  l}-mph  vessels,  those 
lining  the  bloodvessels,  and  those  derived  from  endothelial  cells  which 
surround  the  bloodvessels  in  certain  situations.  \\  e  have,  therefore, 
(i)  Ivmphangio-endotheliomas,  (2)  hemangio-endotheliomas,  and  (3) 
perivascular  endotheliomas,  or,  more  briefl\',  peritheliomas. 

Macroscopic  Appearance. — Endotheliomas  present  a  varied  picture. 
The  t\"pical  form  is  a  more  or  less  globular,  sometimes  slightl}'  lobulated 
tumor,  usuall\"  firm  in  consistency  and  often  dense.  Softer  varieties, 
particularlv  among  the  more  vascular  types,  are  often  encountered. 
Thev  usually  grow  b\'  expansion,  and  therefore  are  more  or  less 
encapsulated.  In  many  instances,  they  develop  difFuseh'  and  may  spread 
over  large  areas.  Occasionally  CA'Stic  dilatations  may  be  observed.  On 
section,  they  are  usually  reddish  gray.  The  cell  strands  can  usually- 
be  made  out  b\'  the  naked  eye. 

Microscopic  Appearance. — Lymphangio-endothelioma. — This  class  is 
the  most  frequent  of  the  endotheliomas,  and  a  network  of  cell  columns 
corresponding  to  the  network  of  lymph  vessels  (Fig.  j})  may  well  be 
taken  as  the  typical  arrangement.  This  comes  about  from  a  prolifera- 
tion of  the  endothelial  cells  which  tend  to  fill  the  lumen  of  the  vessel 
without  invading  the  surrounding  tissue  (Fig.  74).  This  typical  picture 
is  most  likeh-  to  be  found  in  the  periphery  of  the  tumor,  the  more  central 
parts  being  confused  b\'  a  more  advanced  development.  In  the  older 
portions  of  the  tumor  the  connective  tissue  surrounding  the  cell  columns 


138  ENDOTHELIOMAS—CHOLESTEATOMAS 

proliferates   and   the  picture  closely   simulates   a  carcinoma   (Fig.   75). 
The  cells  within  the  columns  may  undergo  certain  changes  which  cause 


Fig.  73 


e"   '■r,    o  «  ' 


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Lymphangio-endo 

thelioma. 

Fig. 

74 

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IS 

r 

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r.-,  ,    'i^ 

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Endothelioma,  showing  columns  of  cuboid  cells  in  tissue  spaces. 


i.Muyriir.i.ioM.is  i:i9 

rluin  to  icstnibli'  rht-  c;iiuii  piarls,  tli()ui;h  kc-ratohyalin  is  always 
absent.  In  otlui- insraiuis  tin-  i  luloihcliomas  may  rc-st-niMc  tin-  saicomas, 
thf  cells  luin^  nunuioiis  ami  spindle-  loiimd.  Tluy  tif(|uc-iul\-  have  a 
coiuiiit  I  K'  an  aniicnu  lit .  I  In-  ilisposnion  ot  i  ndotliclionias  to  resemble 
carcinomas  at  oiu-  pnioil  (»l  tluii  iK  \ clopnunt  and  sarcomas  at  another 
leatls  lliiuke  to  nniaik  that  in  tiiosi'  instances  in  which  one  part  of 
a  tiimoi  siii:;jiests  carcinoma  wliiK-  anotlui  part  suf^f^ests  sarcoma  the 
endothelial  oiiiiin  ot  the  rnmoi  is  probable;  and  it  a  transition  ot  the 
epithelial-like  cells  ot  the  one  into  the  sarcoma-hkc-  cells  ot  the  other 
can  be  made  out,  the  diagnosis  is  certain. 

Fig.  75 


Lymphangio-endotht-lioma,  showing  masses  of  endothelial  cells  enclosed  by  con- 
nective tissue. 

Hemangio-endothelioma. — This  t\pe  springs  from  the  lining  cells  of 
bloodvessels,  which  may  retain  a  patent  lumen  (Fig.  76).  The  cells 
are  continuous  with  the  intima,  and  a  gradual  transition  from  intimal 
cells  to  tumor  cells  must  be  made  out  before  diagnosis  is  possible.  This 
relationship  is  usualh-  most  easily  discernible  in  the  periphery  of  the 
tumor.  The  vessels  may  be  filled  with  columns  of  cells.  Hemorrhage 
into  epithelial  glandular  tumors  or  epithelial  tumors  growing  into  the 
lumen  of  the  vessels  may  simulate  these  tumors.  Certain  capillary 
angiomas  (Fig.  77),  particularly  those  with  hypertrophied  walls,  may 
also  simulate  hemangio-endotheliomas;  indeed,  the  border  line  between 


140  ENDOTHELIOMAS— CHOLESTEA  TOM  AS 

the    two    is    morphologically    indistinct.      The    endothelium    of   vessels 
in  carcinomas  may  proliferate,  simulating  endotheliomas  (Fig.  78). 

Fig  76. 


.-i'?*'^'''.'.^''- 


Hemangio-endothelioma. 

Peritheliomas. — These  tumors  are  formed  from  the  proliferation  of 
the  perivascular  endothehal  sheath.  Since  such  sheaths  are  present 
in  certain  situations  only,  these  tumors  are,  of  course,  restricted  to  the 

Fig.  77 


'  "::-^ir ■r^y'■■i  ',.*■.■•■•.        /<'<%•. 


-     y--^  ',—     -/'  '^   !      ■■  -      -  •'''  '■   "  '  ■'"'  '" 


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.^  >-;;.    -^^^/^^^^i^:^ 

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^.-^'    ■'     ;'■-       "    ^     '"' 

.r '^.^/■^J;;;^i'-_:i 

Capillary  angioma  with  proliferated  endothelium. 

same  locations.  The  tumors  present  intact  vessels  surrounded  by 
concentric  cell  masses  having  a  characteristic  radiating  arrangement. 
These    tumors    even    more    than    the  hemangio-endotheliomas   are    apt 


ESDorilEl.lOM.IS 


141 


to  Ih-  inist;ikin  tor  i;l;iiuiul;ii  tumors,  p:ii  t  Kuhii  1\  ulun  rlu-  source 
of  tin-  tumor  is  not  rakiii  into  account.  I  he  dixulin^,  Imc  between 
rlu-  pcri\ascul;ii  ami  tiidovasculai  tumors  ma\  hi-  ohsiiin-,  lucausc-  the 
(.-nriit-  \t-ss(.-l  ma\'  be  replaced  b\   columns  ot  cells. 

Much  controversy  has  arisen  about  the  relati()nshi|)  between  the 
perixasculai  endotheliomas  and  the  an<i;iosarcomas.  In  all  sarcomas 
the  association  between  the  tumor  cells  and  the  vessels  is  intimate, 
and  if  degenerative  processes  are  active  in  rapidl\'  growing  tumors, 
onl\  those  cells  which  are  situated  immediatel\'  about  the  vessels  and 
thus  retain  their  nutrition,  ma\  keej-)  then  identitw  Such  tumors 
ma\-  resemble  peritheliomas,  but  differ  markedly-  from  them  in  life  his- 
tor\-.  If  tumors  in  which  degenerative  processes  are  not  marked  show 
the  same  appearance,  the\'  may  be  assumed  to  be  peritheliomas.  lo 
use  the  term  angiosarcoma  in  such  conditions  as  a  synonym  for  peri- 
thelioma seems,  therefore,  justifiable. 


Fig.  78 


'% 


■-  %    T     ^  '^i    '■'' 


Proliferated  endothelium  of  vessel  in  breast  carcinoma. 


Various  Other  Types. — Endotheliomas  ma\-  deviate  from  the  usual, 
and  thus  be  recognized  with  difficult}-.  In  the  higher  types  of  cell 
development  tumors  are  produced  which  closely  resemble  the  carci- 
nomas and  adenomas.  Hansemann  has  sought  to  express  their  rela- 
tionship b\-  the  term  carcinoma  endotheliale.  A  closer  approach  to 
the  connective  tissue  may  form  a  tumor  closely  resembling  a  sarcoma, 
which  Hansemann  has  called  sarcoma  endotheliale.  In  such  instances 
the  protean  character  of  the  tumor  is  suggestive  oi  its  true  nature. 
In    those   which     simulate    adenomas     the    absence    of    the    basement 


142  EN  DO  THELIOMAS—CHOLESTEJTOMAS 

membrane  and   the  presence  of  cells  of  var3'ing  sizes,  and,  in  addition, 
their  source  and  location,  make  the  nature  of  the  tumor  clear. 

Various  changes  m  the  form  of  these  tumors  ma}'  take  place,  corre- 
sponding to  the  different  functional  properties  of  endothelial  cells; 
and  the  variations  ma}^  cause  confusion  when  the  complex  character  of 
this  tissue  is  forgotten.  Degenerations  varying  with  the  ty^^t  of  these 
changes  ma}'  also  appear,  such  as  mucoid  and  h}^aline,  giving  rise  to 
the  so-called  cylindromas.  Sometimes  single  la}^ers  of  cuboidal  or  even 
columnar  cells  may  line  connective-tissue  spaces  (Fig.  76).  To  attempt 
to  compare  these  various  forms  with  similar  tumors  of  other  genesis 
is  but  to  add  confusion. 

In  the  diffuse  tumors  of  the  peritoneum  and  pleura  the  question 
of  origin  is  in  dispute.  The  weight  of  evidence  appears  to  favor  the 
assumption  that  they  develop  in  the  subserous  lymph  plexus.  They 
form  plexuses  similar  or  conforming  to  those  of  the  h'mph  vessels,  and 
the  cells  lining  them  are  usuall}'  cuboidal  and  frequenth'  but  one  layer 
deep.  It  has  been  suggested  that  in  some  instances  they  are  either 
metastatic  carcinomas  or  reactive  processes  in  pleuritis.  In  the  pleura 
sometimes  thick  tumor  masses  are  formed  which  fill  a  considerable 
portion  of  the  cavity.  In  the  peritoneum  cystic  tumors  are  frequently 
found. 

The  mixed  tumors  of  the  salivar}'  glands  have  been  included  among 
the  endotheliomas  b}^  man}'  pathologists,  but  since  the  researches  of 
Wilms  there  is  a  disposition  to  class  them  separately  among  the  tumors 
of  congenital  origin.  If  they  are  considered  as  endotheliomas,  the 
presence  of  the  other  tissues  in  them  is  unaccountable;  in  addition  the 
epithelial  cells  are  often  indistinguishable  from  true  epithelium.  In 
their  indolent  course  the}'  resemble  the  endotheliomas;  but  on  the  whole, 
however,  the  mixed  tumors  form  clinicall}'  a  definite  and  well-recognized 
group  and  for  practical  reasons  are  best  considered  b\'  themselves. 

Diagnosis. — Microscopic  Diagnosis. — All  writers  are  agreed  that  a 
positive  diagnosis  is  often  difficult,  sometimes  impossible.  The  clinical 
histor}^  and  location  of  the  tumor  as  well  as  its  macroscopic  appear- 
ance should  always  be  taken  into  account.  The  differentiation  must 
be  made  particularl}'  from  carcinomas,  not  rareh'  from  sarcomas,  and 
occasionall}'  from  reactive  processes. 

Carcinomas. — The  differentiation  from  carcinoma  is  clearly  given 
by  Zeit  as  follow^s: 

I.  The  tumor  cells  in  endotheliomas  are  intimately  connected  with 
the  stroma,  and  cannot  be  brushed  out  of  the  stroma,  as  is  the  case  in 
carcinoma  in  which  the  epithelial  cells  may  retract  from  the  stroma 
and  show  spaces. 


EMXJTIIl.l.lOM.IS  14:i 

2.  Kndotlulial  cills  piocliict-  iiitcictllular  siil)staiice  aiul  are  packctl 
together  closely;  Init  the  epithelial  cells  in  cancer  have  no  intercellular 
substance  and  ilo  nor  torin  compact  la\  crs. 

3.  In  eiulothehonias  delicate  hhiillai  processes  extend  from  the  walls 
of  the  aKeoli  into  the  inolitei  ated  endothelial  cell  masses.  I  hese  are 
absent  m  carcinoma. 

4.  In  eiuiotlu  lioma  the  cell  masses  consist  oi  a  dense  mosaic  of  man\' 
la\ers  of  cells,  with  small,  sharply  outlined  nuclei,  surrounded  b\'  a 
broad  einelope  of  clear,  glassy  perinuclear  protoplasm.  Carcinoma 
cells  ha\e  \esicular  nuclei,  with  a  moderate  amount  of  more  or  less 
granular  perinuclear  jirotoplasm. 

5.  In  endothelial  tumors  the  cells  aie  arranged  in  the  fcjrm  cjt 
cellular  cords,  or  the  cords  or  cylinders  may  be  hollowed  out  by  the 
secretory  processes  of  the  endothelial  cells. 

Sarcomas. — The  chief  differentiating  point  from  sarcomas  is  that 
in  the  latter  the  arrangement  of  the  cells  and  intercellular  tissue  is 
more  diffuse,  whereas  in  endotheliomas  cells  are  surrounded  b}-  fibrous 
tissue  after  the  manner  of  a  carcinoma.  The  fact  that  this  distinction 
has  been  often  overlooked  is  responsible  for  the  use  of  the  term  "alveolar 
sarcoma"  to  designate  certain  endotheliomas. 

Reactive  Forms. — The  plexiform  endotheliomas  may  resemble  very 
closelv  the  plastic  h'mphatics  as  seen  in  syphilis.  Diagnosis  must 
depend  upon  the  presence  of  other  signs  of  syphilis.  In  various  lymphatic 
irritations,  such  as  elephantiasis  or  inflammatory  reactions,  particularly 
in  l^mph-gland  sinuses,  the  endothelium  may  become  piled  up  and 
suggest  endothelioma.  In  the  borders  of  carcinoma,  too,  the  l\'mphatic 
vessels  ma^'  respond  to  the  irritation  b\"  proliferating. 

Clinical  Diagnosis. — The  endotheliomas  spring  from  tissue  devoid 
of  epithelium,  and  have  a  characteristic  clinical  historw  \\  hether 
they  form  globular  or  diffuse  tumors,  they  grow  slowly  and  show  little 
disposition  to  metastasize.  These  clinical  facts  frequently  point  to 
the  correct  diagnosis,  when  the  microscopic  findings  are  obscure.  Some- 
times after  man}'  \-ears  of  latency  they  begin  to  grow  suddenly  and 
may  then  form  metastases.  In  tumors  with  such  histor\'  particular 
care  is  required  to  make  an  exact  diagnosis.  In  certain  regions  endo- 
theliomas present  characteristic  peculiarities,  which  will  be  considered 
in  the  regional  consideration  of  tumors. 

Treatment. — Because  of  the  disposition  to  local  recurrence,  broad 
local  excision  should  be  the  treatment.  Dissection  of  regional  lymph 
glands  is  not  required.  Recurrences  require  prompt  excision,  and  usually 
after  a  time  complete  cure  is  effected.  Those  types  which  closely  re- 
semble carcinoma  sometimes  ulcerate  but  do  not  form  metastases  until 
ver\'  late. 


144  ENDOTHELIOMAS— CHOLESTEATOMAS 


CHOLESTEATOMAS^ 

Two  conditions  have  been  described  under  this  head.  The  more 
common  type  is  not  a  true  tumor,  but  more  nearly  a  keratosis  of  the 
middle  ear  or  antrum,  and  may  fill  these  spaces.  The  true  type  resembles 
the  endotheliomas.  They  are  formed  of  little  nodes  of  endothelioid 
cells,  and  they  derive  their  name  from  the  crystals  of  cholesterin  found 
m  their  centre. 

For  literature  see  Bostroem,  Centralbl.  f.  allg.  Path.,  1897,  viii,  i. 


(■  II  A  I'  I"  K  R     XIII 
ADKNOMAS 

Conception  and  Types.  Adenomas  hear  the  same  relation  to  glandular 
epithelium  that  papillomas  do  to  protective  epithelium.  Adenomas 
are  ot  two  \arieties,  correspondintr  to  the  two  anatomical  relatujns  of 
the  gland.  Those  glands  which  line  surfaces  (intestmes,  uterus),  when 
they  proliferate,  imitate  in  a  general  wa\'  the  external  form  of  papillomas. 
This  comes  about  because  the  glandular  increase  takes  place  in  the 
direction  of  least  resistance,  that  is,  on  the  surface.  Those  glands  whose 
secretions  are  carried  off  by  outlet  ducts  imammar\',  parotid),  or  those 
which  have  no  outlet  at  all  (th\roid),  form  more  or  less  globular  masses, 
since  the  resistance  is  the  same  on  all  sides.  The  principle  of  growth 
is  the  same  in  both  and  the  difference  in  form  is  a  topographical  con- 
sideration w^ithout  biological  importance.  In  both  cases  the  prolifera- 
tion exceeds  the  normal,  but  the  cell  type  changes  little.  As  the  glands 
develop,  the  connective  tissue,  including  the  basement  membrane, 
develops  with  them.  The  glandular  secretion  continues,  but  there  is 
both  a  quantitative  and  a  qualitative  change,  as  is  seen,  for  example, 
in  the  production  of  colloid  material  in  the  breast  and  the  stomach. 
In  some  instances  the  deviation  from  the  normal  is  wider  and  no  secre- 
tion is  produced. 

Polypoid  Type. — This  type  resembles  in  general  form  the  mucous 
pohps.  Instead  of  merely  a  mucous  covering,  as  in  the  polyps,  the 
entire  mass  is  made  up  of  increase  in  glands  with  a  small  amount  of 
connective  tissue.  The  glands  composing  these  tumors  are  increased 
in  length,  become  branched,  and  ramify  in  a  complicated  manner.  The 
external  form  of  the  tumors  is  usuall\'  irregularly  globular,  more  rarely 
pedunculated.  If  the  outlet  of  the  gland  becomes  occluded  the  reten- 
tion of  the  secretion  gives  rise  to  c\sts. 

These  tumors  are  often  multiple  (intestines,  stomach)  and  ma\-  be 
observed  in  early  life,  both  factors  suggesting  an  embryonal  origin. 
These  tumors  may  lie  dormant  for  indefinite  periods  or  ma\-  take  on 
a  rapid  growth  and  become  malignant. 

Microscopically,  the  bod\-  of  the  tumor  is  composed  of  a  network 
of  glands  and  bloodvessels  in  a  matrix  of  connective  tissue.  1  he  glands 
retain  the  general  character  of  glands  peculiar  to  the  part.  The  cells 
remain  one  layer  deep;  the  staining  properties  are  unchanged  and 
mitotic  figures  are  absent.     The  glands  are  limited  definitely   by   the 

10 


146  ADENOMAS 

basement  membrane.  The  connective  tissue  varies  much  in  amount. 
It  may  be  abundant,  but  it  usually  is  barely  sufficient  to  sustain  the 
bloodvessels.  In  some  cases  there  is  evidence  of  fibrous  and  inflam- 
matory changes,  especially  in  the  pedunculated  tumors.  The  vessels 
may  be  dilated  into  sinuses.  In  the  stalked  tumors  myxoid  degenera- 
tion is  likely  to  occur  on  account  of  disturbances  of  the  circulation. 
The  dividing  line  between  this  class  and  the  polyps  is  not  sharp. 

Closely  resembling  the  surface  adenomas  are  certain  growths  allied 
to  inflammatory  processes.  They  are  formed  most  frequently  in  the 
uterus  and  sometimes  in  the  rectum.  They  are  diff"use  and  seldom  form 
a  tumor  in  the  strict  sense  of  the  word.  They  consist  in  an  increase 
in  the  gland  with  more  or  less  of  the  connective  tissue.  The  glands 
resemble  those  in  inflammatory  conditions,  and  seem  affected  by  an 
irritative  rather  than  by  a  neoplastic  process.  They  increase  in  size 
rather  than  in  number,  so  that  various  puzzling  forms  are  produced. 
As  they  grow  in  length  they  become  folded  upon  themselves  or  become 
S-shaped,  or  they  may  become  telescoped,  so  that  a  gland  is  seen  within 
a  gland.  The  interstitial  tissue  usually  shows  some  activity,  enough 
in  some  cases  even  to  resemble  sarcoma.  These  deceptive  pictures 
are  seen  almost  entirely  in  the  uterus.  Such  conditions  are  better 
called  polypoid  hypertrophies.  In  the  intestinal  canal  it  is  often  im- 
possible to  determine  whether  they  are  congenital  or  inflammatory 
in  origin. 

Intraglandular  Type. — This  type  of  adenoma  is  formed  by  the  pro- 
liferation of  a  glandular  organ.  The  growth  is  expansile  and  pushes 
the  surrounding  tissues  before  it,  the  general  principles  of  growth  being 
apparently  the  same  as  in  the  superficial  type.  They  are  usually 
embryonal  in  character.  Local  irritation  plays  a  less  important  part 
than  with  the  polypoid  type.  Such  tumors  may  appear  at  a  period 
of  maximum  physiological  activity  (mamma,  thyroid)  or  at  a  time 
when  the  glands  are  undergoing  involution  (mamma,  liver).  The  glands 
vary  greatly  in  the  hyperplasia  which  they  undergo.  Secretions  may 
accumulate  and  form  cystic  dilatations  or  the  glands  may  become 
filled  by  papillary  growths  into  their  own  lumina.  There  is  no  round- 
celled  infiltration.  The  connective  tissue  is  dense  and  free  from  the 
cellular  elements  and  varies  in  amount  (Fig.  79).  Frequently  it  is 
so  much  more  abundant  than  the  glandular  element  that  the  growth 
may  appear  to  belong  to  the  connective-tissue  tumors  (fibro-adenoma 
of  the  breast)  (Fig.  80).  The  bloodvessels  are  sparsely  developed.  The 
tumors  are  encapsulated. 

Glandular  hyperplasias,  the  result  of  irritative  processes,  or  accom- 
panied by  them,  often  play  a  role  in  this  type  (prostate,  sweat  glands, 
thyroid),  and  the  border  line  between  them  is  often  difficult  to  draw. 


IMR.IC.L.IXDL  L.IR   lYI'l.   (J/    ,//)J.\fj.\L/S 


\M 


Diagnosis.      I  he    ckrtriiiinin^i    cliaractiristii    ot    an    adenoma    is    the 

Muiiast    ot    rlu-   ^laiicl    cKiiuius    wirlioiir    ^iiat    icrio^in-ssion    from    the 

Kk;.  79 


//'e'-'ir, 


:  i- 


Adenoma  of  the  thyroid  gland. 

adult  gland  form  and  without  disposition  to  invade  the  surrounding 
tissue.  The  first  change  in  an  adenoma  toward  malignancy  is  the  piling 
up  of  the  epithelium  (Fig.  8i).     These  earl\'  changes  have  been  elabo- 


FiG.  80 


wA 


% 


'-"V^^^H^aig^ 


=5=i" 


^ 


'^-r.^ 


Adenoma  of  breast. 


rately  worked  out  by  Amann  and  others.     In  a  normal  gland  the  division 
of  the  cells  is  in  the  direction  of  the  transverse  a.xis  of  the  gland,  while 


148  ADENOMAS 

in  beginning  malignancy  the  line  of  division  is  in  the  longitudinal  axis 
of  the  gland.  The  result  of  this  is  that  the  gland  cells  become  more 
than  one  cell  layer  deep.  The  value  of  these  observations  is  slight, 
for  in  some  adenomas  the  epithelium  piles  up  and  gives  the  microscopic 
appearance  of  malignancy,  though  the  tumors  may  be  clinically  benign. 
The  crucial  test  in  such  instances  is  the  relation  of  the  newly  formed 
glands  to  the  connective  tissue,  particularly  the  basement  membrane 
when  one  is  present.  In  one  which  projects  from  the  surface  it  is 
necessary  to  section  its  base. 

It  was  formerly  the  custom  to  distinguish  a  class  of  malignant  adeno- 
mas. These  were  regarded  as  similar  to  the  above  tumors,  inasmuch 
as  the  cells  remained  one  layer  deep  but  that  the  cell  columns  invaded 
the  surrounding  tissue.  Experience  has  shown  that  when  the  surround- 
ing tissue  is  invaded  the  cells  become  more  than  one  layer  deep  and 
approach  the  simple  carcinoma.  Confusion  is  avoided  by  classing  all 
adenomas  which  invade  the  surrounding  tissue  with  the  carcinomas, 
since  the  criterion  in  all  instances  is  the  relation  to  the  surrounding 
tissue. 

Fig.  8i 


i~^< 
-?»«.„ 


<3Sj 


Malignant  adenoma,  showing  the  piling  up  of  the  cells. 

Prognosis. — Simple  adenomas  are  benign  tumors,  and  when  removed 
do  not  recur.  To  what  extent  they  tend  to  become  malignant  is  very 
uncertain.  Some  authors  maintain  that  when  a  malignant  growth 
appears  in  connection  with  an  adenoma  it  is  an  invasion  from  a  neighbor- 
ing carcinoma  which  has  developed  independently.  This  explanation 
is  unsatisfactory  from  a  pathological  viewpoint,  and  it  does  not  harmonize 
with  observed  facts.  On  the  other  hand,  it  seems  quite  reasonable  to 
assume  that  tissue  which  has  undergone  abnormal  proliferation  within 
its  histological  boundaries  may,  in  response  to  further  stimulus,  undergo 


TkE.ir.MEsr  oi    idesom.is  mu 

a  still  inoif  actiN'f  growth,  pciutiart-  rlusc  hoiiiulaiKs,  and  invade  the 
sunouiulinii  tissue.  It  imist  he  contessecl  that  we  ha\e  no  means  of 
deterniininji  wlurlui  m  not  a  jj;i\'en  tumor  will  under j^o  such  a  change, 
nor  from  microscopic  examination  of  a  malij^nant  growth  is  it  al\va\s 
possihle  to  say  it  a  previously  hemjiii  state  has  existed.  Clinical  evi- 
dence does  not  hear  upon  this  point,  and  not  infrecpienth  adenomas 
which  are  in  the  mam  typically  benign,  may  show  areas  that  have 
become  malignant.  Others  in  which  the  entire  tumor  is  malignant, 
upon  examination  present  histories  which  indicate  that  they  too  had 
a  preliminary  benign  stage.  To  assume,  as  some  pathologists  do,  that 
such  were  malignant  from  the  start,  fails  to  account  for  their  prolonged 
quiescent  existence  and  their  sudden  exacerbation.  On  the  other  hand, 
It  IS  quite  in  accord  with  clinical  experience  to  regard  the  (juiescent 
stage  as  adenomatous  and  benign  and  the  malignant  stage  as  having 
developed  from  this  because  of  some  stimulus.  For  these  reasons 
prognosis  of  adenoma  must  be  made  with  a  certain  reserve. 

Treatment. — Local  removal  is  sufficient  m  simple  adenoma.  He- 
cause  malignant  changes  occasionally  occur  removal  should  be  complete. 
This  need  is  emphasized  by  the  fact  that  it  is  at  the  base  where  the 
first  evidence  ot  malignanc}'  is  observed.  Since  different  types  show 
a  diHerent  disposition  to  such  a  change,  the  type  must  modify  the 
treatment.  The  accessibility  of  the  tumor  obviously  must  also  be 
considered    in    treatment. 


CHAPTER    XIV 
PAPILLOMAS 

Definition  and  Classification. — No  other  group  of  tumors  contains 
such  a  heterogeneous  variety  as  the  papillomas.  Under  this  head  are 
mcluded  tumors  unquestionably  fibrous  in  character  and  others  as 
certainly  epithelial.  Each  of  these  types  has  an  acquired  and  a  con- 
genital representative.  The  granulomas  and  also  certain  non-specific 
inflammatory  processes  are  attended  by  papillary  formations.  In 
addition  many  of  the  hemangiomas  and  lymphangiomas  in  which  the 
connective  tissue  is  abundant  are  papillomatous. 

On  account  of  the  lack  of  relationship  among  these  tumors  it  is  impos- 
sible to  enter  into  a  general  discussion  as  to  their  cause  and  nature. 
The  term  "papilloma"  has  no  justification  except  in  a  clinical  sense, 
for  these  growths  are  similar  only  in  that  they  form  masses  which  pro- 
ject more  or  less  beyond  the  surface  upon  which  they  are  situated. 
The  different  varieties  may  therefore  be  taken  up  in  order. 

Fibrous  Papillomas  (Fig.  82). — This  variety  belongs  unquestionably 
to  the  fibromas,  as  Virchow  contended.  They  are  small,  smooth  tumors, 
with  a  base  which  varies  in  extent  as  compared  with  the  apex  of  the 
tumor.  Some  are  distinctly  pedunculated.  They  are  usually  multiple, 
and  their  frequent  symmetry  has  been  regarded  as  evidence  of  con- 
genital origin.  They  are  made  up  of  fibrous  tissue  and  vary  in  density. 
The  bloodvessels  may  be  wide,  but  their  walls  are  definitely  formed, 
and  may  or  may  not  have  groups  of  embryonal  cells  about  them  (Fig. 
83).  The  epithelial  covering  is  often  no  different  from  that  of  the 
surrounding  skin.  Usually,  however,  the  papillae  are  obliterated,  par- 
ticularly if  the  tumor  is  of  some  size. 

Epithelial  Papillomas. — Birch-Hirschfeld's  contention  that  papillomas 
should  be  classed  with  the  epithelial  growths  finds  justification  in  this 
group.  Because  of  differences  in  life  history  rather  than  in  structure 
it  is  desirable  to  divide  them  into  adolescent  and  senile  varieties. 

The  adolescent  papillomas  are  the  common  "warts"  seen  on  the 
fingers  and  hands  of  young  persons.  They  are  not  seen  at  birth,  and 
their  origin  is  often  as  mysterious  as  their  disappearance.  They  are 
made  up  of  a  connective-tissue  centre  bearing  bloodvessels,  sometimes 
of  large  size,  with  definitely  formed  walls.  The  staining  reaction  of 
the  connective  tissue  is  distinctly  acidophilic.     The  epithelium  is  much 


Ei'iriiEi.i.ii.  r. It'll. m.M.is  loi 

Kk;.  M2 


•   iv    "^^  --"■'""•.  :••-  •    ■•;••■ 


■  <-\\i  o'-'-j 


s  •'• 


t^ibrous  papilloma  of  the  face,  showing  epidermal  covering,  loose  fibrous  tissue,  and 

bloodvessels. 


Fig.  83 


1"- 

•/^^.: 

'     ^'i'\     ..■'■■■     • '^:  •■■■:'.■-  . 

">  • 

C'*^'^, 

, 

'0 

^''^f.^ 


Fibrous  papilloma,  showing  epidermis,  connective  tissue,  and  vessels  surrounded 

bv  embr\onal  cells. 


152  PAPILLOMAS 

thickened  in  comparison  to  the  normal  skm,  and  sometimes  the  super- 
ficial layer  of  keratin-containing  cells  is  enormously  thickened,  giving 
rise  to  a  horny  formation.  The  transition  of  epithelium  in  thickness 
from  the  normal  skin  to  the  highest  point  is  usually  gradual,  so  that 
there  is  no  sharply  defined  border,  and  the  impression  is  therefore 
of  an  hypertrophy  rather  than  of  a  tumor  formation;  the  epithelium 
may  project  deeply  into  the  fibrous  tissue,  but  sometimes  the  tumors 
are  sharply  defined,  so  that  the  epithelium  covering  the  growth  sepa- 
rates readily  from  the  normal  epidermis. 

The  senile  wart  (Fig.  84)  occurs  oftenest  on  the  face  and  generally 
in  persons  beyond  the  fiftieth  year.  In  form  and  structure  they  differ 
little  from  the  adolescent  wart.     There  is  often  evidence  of  a  disturbed 

Fig.  84 

V-.-  ■      ■       ,        ■  '         ■{    ,:/••   \     / 


% 


/^ 


*^/,^ 

:"-;■? 


2^- 


Epithelial  papilloma  (senile  wart). 


relationship  between  epithelium  and  connective  tissue,  manifested 
by  a  lessened  affinity  of  the  connective  tissue  for  the  acid  dyes  and 
by  areas  of  round-celled  infiltration.  That  there  is  some  epithelial 
proHferation  is  indicated  by  a  stronger  reaction  to  the  basic  stains. 
There  is  frequently  evidence  of  a  more  active  branching  of  the  cell 
columns  than  in  normal  areas  and  occasionall}^  some  irregularity  in 
the  size  of  the  cells.  All  of  these  observations  are  in  accord  with  the 
well-known  disposition  of  these  tumors  to  undergo  malignant  change. 
Melanotic  Papillomas  (Nevus  Pigmentosis,  Fig.  85). — Under  this  head 
may  be  collected  those  congenital  lesions  of  the  skin  which  are  usualh^ 
characterized  b}^  abnormal  pigmentation.  They  vary  in  color  from 
pale  yellow  to  black,  depending  on  the  amount  of  pigment  present. 
Occasionally  there  may  be  an  entire  absence  of  pigment,  although  the 


.\ii:i..i.\()Ti{:  I'.ii'ii.i.oM.is 


I5:i 


tumor  in:i\'  intscnr   tin-  mm  r;il  ih;ir;icrcnsrics  ot  rlu-  >;r<)iip,  hut  in  the 
niaj()rit\     ot    (.iisis    a    caittul    scanli    will    dist-losc-    pij^nunt.       1  ht\'    are 

Vu,.  S5 


Melanotic  iiapillonia   (piiiiiuiir  wart),  showinji  epidermis  and  embryonal  cells  with 

areas  of  pigment. 

usually  flat   turiiors   (Fig.   86)    reaching  but  slightly   above  the  surface 
of  the   skin   and   without   a   constricted    base,   although  in   some  cases 


-C 


Pigmented  mole:  a,  pigment  cells;   b,  embnonal  cells;  r,  epidermis 

they  may  be  pedunculated  (Fig.  87).     Sometimes  there  is  no  e 
but  simpl}-  a  pigmented  area  in  the  skin.     Often  these  tumors 


levation, 
are  ver\' 


154  PAPILLOMAS 

vascular  (Nevus  vascularis),  and  sometimes  they  are  covered  bv  a 
growth  of  hair  (Nevus  piliaris).  An  endless  number  of  names  has  been 
applied  to  variations  from  the  common  tA'pe.  The  pigmented  nevi 
are  usually  congenital,  and  their  growth  is  in  proportion  to  the  growth 
of  the  child.  Thev  are  frequentl}'  multiple,  and  are  sometimes  s}'m- 
metrically  arranged  in  such  a  way  as  to  suggest  some  relation  to  the 
nervous  system.  Their  structure  is  variable,  and  the}'  merge  insensibly 
into  the  soft  papillomas.  The  nature  of  these  tumors  has  not  yet  been 
fully  determined.  Borst^  classes  them  with  the  fibromas,  and  v.  Reckling- 
hausen regarded  them  as  l)'mphangiofibromas.  Frequentl}'  the^'  are 
accompanied  b)'  a  considerable  development  of  fibrous  tissue.  Bauer- 
regards  them  as  endothelial  m  character.     The  cells  are  often  grouped 

Fig.  87 


^  /"  -•^/ 

.:■/  :-■;"- W^__ 

^  ^ 

''%    '■'  :' 

'-^ 

;-/  ^  ■'     ■^''.:'\ 

V-.V 

■^^r 


1P- 


Pedunculated  melanotic  papilloma.     The  epidermis  contains  pigment  in  the  deeper 
layers.     The  embryonal  cells  are  free  from  pigment. 

about  the  vessels  and  often  have  an  alveolar  arrangement,  which  may 
be  retained  when  they  undergo  rapid  development.  Unna,-^  on  the 
other  hand,  regards  the  cells  which  characterize  these  tumors  as  of 
epithelial  origin.  Ribbert^  classes  them  under  a  separate  head  as 
melanomas  or  chromatophoromas.  The  latter  term,  except  for  the  lack 
of  euphony,  is  preferable,  since  it  emphasizes  the  fact  that  the  essential 

^  Lehre  von  den  Geschwiilsten,  Bergmann,  Wiesbaden,  1902,  i,  117. 

^  Virchow's  Arch.  f.  path.  Anat.,  1895,  cxlii,  408. 

^  Ibid.,  1896,  cxliii,  224. 

*  Geschwiilstlehre,  Cohen,  Bonn,  1904,  p.  255. 


MUCOUS  I'.II'II.I.OM.IS  155 

natiiic  ot  rlu-  tmiiDi  lies  in  tlu-  chIIs,  whiili  show  a  disposition  to  pigment 
foi  niarioii.  All  orlu  r  factors,  papillar\-  toniiation,  the  rtlativc  proportion 
ot  tihroiis  rissiu-  or  \tssfls,  is  unimportant.  I  In-  distiissioii,  too,  as  to 
the  origin  of"  thtsc  cells  is  irrelevant.  There  can  be  no  doubt  of  their 
orif^in  in  c()n<ieniral  misplacements,  and  it  is  of  no  importance  to  which 
adult  cells  the\  an-  most  close!)'  related,  since  they  show  characteristics 
not  possessed  by  any  adult  cell. 

riu-  cells  which  are  peculiar  to  these  tumors  are  usually  spindle 
form  and  often  have  numerous  processes,  which  may  extend  mto  the 
lower  la\ers  of  the  epidermis,  bur  usuall\'  there  is  an  area  free  from 
them  immediately  under  the  epidermis.  On  the  lower  border  the  cell 
processes  extend  into  the  subdermal  tissue  and  are  often  grouped  about 
l\mph  vessels.  The  pigment  is  usually  deposited  about  or  in  these  cells, 
but  also  quite  as  often  in  the  lower  cells  of  the  epidermis  and  some- 
times even  in  the  epidermis  alone.  The  frequent  occurrence  of  pigment 
in  the  spaces  between  the  cells  is  believed  to  be  due  to  liberation  of 
the  pigment  by  destruction  of  the  cells.  The  irritation  produced  by 
these  pigment  granules  upon  the  lymphatic  vessels  is  regarded  b\- 
Borst  as  an  important  factor  in   the  production  of  malignant  tumors. 

The  cause  of  the  change  in  the  character  of  the  cells  is  not  under- 
stood, but  their  disposition  to  rapid  growth  and  metastasis  gives  them 
a  peculiar  importance  in  oncology.  Spontaneoush',  or  as  the  result 
of  trauma,  these  stumors  proliferate  and  give  rise  to  melanosarcomas 
iq.  v.).  There  can  be  no  doubt  but  that  the  malignant  tumors  are  the 
descendants  of  the  group  of  cells  within  the  pigmented  nevi,  \-et  the_v 
give  no  additional  clue  to  the  origin  of  these  cells.  Lubarsch'  and 
Abesser-  consider  these  tumors  epithelial,  and  propose  the  term  "nevo- 
carcinoma.''  The  disposition  of  these  tumors  to  metastasize  first  by 
the  h'mphatics  presents  some  resemblance  to  the  epithelial  tumors, 
but  their  disposition  later  to  form  generalized  metastases  brings  them 
in  closer  relation  to  the  sarcomas.  Since  the\-  are  general!}'  considered 
as  sarcomas,  they  are  discussed  with  that  group. 

Mucous  Papillomas  (Fig.  88). — The  soft  papillomas  are  found  in 
mucous  surfaces.  They  appear  as  complicated  villiform  tumors,  which 
frequent!}'  branch  like  a  tree.  A  fibrous-tissue  matrix  occupies  the 
centre  and  is  everywhere  covered  with  epithelium.  It  is  continuous 
with  the  mucous  tissue  and  is  usualh'  small  in  amount  compared  with 
the  epithelium.  It  is  rich!}'  supplied  with  bloodvessels  which  may  be 
dilated  in  places.  The  fibrous  tissue  ma}'  be  edematous  and  resemble 
m}-xoma.     The  epithelium  ma}'  retain  the  normal  form  or  ma}'  undergo 

•  .A.rb.  aus  dem  Inst,  zu  Pasen,  1901. 

-  Virchow's  Arch.  f.  path.  .Anat.,  1901,  cxlvi,  40. 


156  PAPILLOMAS 

metamorphosis,  the  cells  changing  from  ciliated  to  simple  columnar 
or  cuboidal,  and  finally  becoming  irregular  in  form.  This  change  is 
often  more  active  in  the  exposed  parts  of  the  tumor,  and  the  protected 
parts  may  retain  their  normal  characteristics.  The  cells  are  sharpl}^ 
limited  by  the  fibrous  tissue,  but  that  there  is  a  certain  degree  of  rest- 
lessness is  indicated  by  the  not  uncommon  mitosis.  Many  of  the  cells 
when  exfoliated  show  a  spindle  shape  which  is  more  or  less  peculiar 
to  these  growths.  The  mucous  papillomas  occur  most  frequenth*  in 
the  bladder,  kidney,  and  urethra,  less  often  in  the  gastro-intestinal 
tract,  nose,  pharynx,  uterus,  and  Fallopian  tubes.  They  not  infrequently 
undergo  malignant  changes,  the  cells  invade  the  base  and  spread  into 
the  surrounding  tissue.  For  indication  of  the  change  it  is  necessary 
to  examine  the  cells  at  the  base  of  the  tumor,  because  the  epithelium 
of  the  projecting  parts  may  show  extensive  proliferation  quite  apart 
from  malignant  degeneration. 

Fig.  88 

^■^  ,►  t^  <. 


Papilloma  of  the  endometrium. 

Condylomas  (Fig.  89). — The  condylomas  are  not  true  tumors,  inasmuch 
as  they  are  dependent  on  obscure  local  inflammatory  conditions.  They 
form  cauliflower-like  growths  varjang  in  size  from  a  pinhead  to  a  small 
apple.  They  are  most  frequently  located  about  the  external  genitalia 
and  anus,  and  are  associated  with  chronic  gonorrhea  or  other  venereal 
discharges,  or  with  any  chronic  irritative  process.  The  surface  is  covered 
by  a  thick  layer  of  epithelium,  with  large  pale-staining  nuclei  and  a 
large  amount  of  homogeneous  protoplasm  having  a  slight  affinit}'  for 
dyes.  The  deeper  epithelium  has  the  same  characteristics.  The  fibrous 
tissue  is  not  abundant,  but  contains  numerous  small  vessels  and  a  large 
number  of  round  cells. 

Cornua  Cutanea  (Fig.  90). — These  are  rare  tumors  which  are  found 
about  the  border  of   the  scalp,  the  face,  the  hands,  and    rarely  about 


CORM  ./   CL   r.lM:.! 


the  external  j2:enitali;i.      'I"lu\    lonsist  of  an  t-normous  thickening 
epirhrlium,    with    eontspontlini;    proloniiations    of    the    papill:e. 


.r  the 
Ihev 


Syphilitic  condyloma. 
Fig.  90 

/,  /■,■■■  •  ■' 


I  ll'\^*' \^  v^\  ■■■■'■^■.   I-  / 
'h-^:  '■  '.  it 'Ml 


3l^ 


Hornv  wart. 


158  PAPILLOMAS 

sometimes  become  several  inches  long,  and  when  they  occur  on  the  fore- 
head well  deserve  their  popular  name  of  "horns."  Instead  of  a  single 
more  or  less  cylindrical  projection  the  surface  may  be  irregular.  Borst 
thinks  they  do  not  cause  cancer,  but  it  appears  to  me  that  a  causative 
relationship  is  probable,  since  I  have  observed  two  instances  in  which 
carcinomas  developed  about  their  base.  They  are  probably  but  a 
modification  of  senile  warts. 

Diagnosis. — It  is  easier  to  differentiate  the  various  papillomas  above 
mentioned  than  it  is  to  form  a  coherent  classification  of  them.  The 
difi^erences  have  already  been  sufficiently  emphasized.  The  importance 
of  the  various  types  consists  in  their  latent  malignancy,  each  of  them, 
excepting  the  fibroid  papillomas  and  the  adolescent  warts,  being  sub- 
ject to  malignant  change.  In  any  case  such  a  change  can  be  detected 
only  when  the  relation  of  the  base  of  these  tumors  to  the  surrounding 
tissue  can  be  examined.  This  is  particularly  true  of  the  fungiform 
epithelial  types,  notably  those  occurring  in  the  bladder  and  the  intes- 
tinal tract.  The  examination  of  the  pendulous  portion  of  these  tumors 
is  of  no  value.  The  base  and  the  surrounding  normal  tissue  must  be 
included  in  the  section  if  examination  is  to  be  of  any  value. 

Specific  processes  may  give  rise  to  papillary  tumors.  These  belong 
to  the  granulomas,  and  will  be  considered  under  that  caption. 

Treatment. — The  soft  fibrous  and  adolescent  types  may  be  excised 
or  destroyed  by  escharotics.  The  senile  warts  should  be  excised.  Under 
no  condition  should  they  be  treated  by  local  caustics  such  as  are  used 
upon  the  adolescent  variety.  Such  treatment  serves  only  to  stimulate 
to  malignant  changes.  Of  greater  importance  are  the  pigmented  variety, 
especially  the  solitary  growths  of  the  temple,  thigh,  and  arm.  The 
prophylactic  removal  of  these  has  been  repeatedly  advocated. ^  When 
they  are  multiple,  and  particularly  on  the  back,  they  are  much  less 
likely  to  undergo  malignant  change. 

^  Keen,  Jour.  Amer.  Med.  Assoc,  1904,  xliii,  96. 


CHAP  r  K  k    X  y 


CARCINOMA 


General  Conception,  I  In-  papillomas  and  picccdin^  types  of  epirlu- 
lial  rimiois  arc  mack-  up  ot  t-pithelial  and  connective  tissue  in  (liferent 
proportions,  the  epitlielium  changed  httle  if  at  all  from  the  normal. 
Carcinomas  are  likewise  composed  of  epithelium  and  connective  tissue, 
hut  the  epithelium  deviates  from  the  normal  toward  a  less  differentiated 
or  embr\onal  type.  Fhe  cells  do  not  bear  the  normal  histological  rela- 
tion to  connective  tissue  as  in  the  benign  tumors,  but  tend  to  invade 
it  and  the  other  surrounding  tissues,  thus  declaring  their  freedom  from 
the  restraining  influence  of  their  environment.  A  carcinoma,  then, 
may  be  defined  as  a  fibro-epithelial  tumor,  the  epithelium  of  which 
deviates  more  or  less  from  the  normal  t\pe  and  tends  to  invade  the 
surrounding  tissue. 

The  difference  between  the  benign  and  the  malignant  epithelial 
tumors  can  be  appreciated  best  b}'  considering  their  respective  modes 
of  growth.  If  a  vet}-  early  cancer,  as  on  the  face,  is  examined  by  the 
microscope,  it  will  be  discovered  that  at  some  point  the  epithelium  is 
beginning  to  proliferate  as  in  a  papilloma,  save  that  the  new  cells  do 
not  exactly  resemble  the  mother  cells.  The  degree  ot  this  deviation 
varies  greath'  in  different  tumors;  it  may  be  slight  or  may  be  so  great 
that  the  cell  loses  all  resemblance  to  epithelium,  and  becomes  embryonal. 
While  this  change  is  taking  place  the  new^  cells  are  invading  the  sur- 
rounding tissue,  which  thereupon  reacts  against  them  by  developing 
new  connective  tissue  It  is  the  amount  and  character  of  this  reaction, 
and  the  degree  and  kind  of  deviation  of  the  epithelial  cells  from  the 
normal  which  give  to  carcinomas  their  remarkable  variation  in  structure 
and  life  historw  The  question  of  the  relation  of  the  surrounding  normal 
tissue  to  the  carcinoma  cells  has  given  rise  to  much  controvers\'.  It 
has  now  been  quite  definitel\'  established  that  the  tumor  arises  at  one 
point,  and  as  it  grows  the  surrounding  tissue  is  displaced  but  does  not 
itself  become  carcinomatous.     (See  Growth  of  Tumors,  p.  24.) 

As  a  concrete  example  of  these  relations  one  may  compare  a  papilloma 
with  a  beginning  epithelioma.  In  the  former,  the  epithelium  is  increased, 
but  there  is  no  change  in  cell  t^pe;  the  connective  tissue  is  unchanged 
or  ma\'   be  increased   as  if  to  provide  added   resistance   (Fig.  91).      In 


160  CARCINOMA 

the  beginning  epithelioma  there  is  also  an  epithelial  overgrowth,  but 
the  cell  type  is  changed   (Fig.  92)  and   the  connective  tissue  no  longer 

Fig.  91 


s.  J^ 


^■^y 

^''r 


'         -vj ^^  '  ' 


/ 


Papilloma  of  the  lip.     The  epithelium  is  overgrown  and  there  is  an  increase  in  the 

connective  tissue. 


Fig.  92 


V%^''-^|<i 


:^5-?\. 


'«■  V  ,■  .,./%&■■ 


Beginning  carcinoma  of  lip,  showing  advancing  cell  columns  with  deeply  staming 
cells  and  increased  connective  tissue. 

Stains  so  deeply  with  acid  dyes.  In  more  advanced  tumors  or  in  those 
of  greater  initial  mahgnancy  these  changes  are  exaggerated  (Fig.  93), 
and  there  is  extensive  round-celled  infiltration. 


riiYsic.ii.  i.ii.ik.icri.Rs  or  c.ikc.isom.i  i<ii 

Physical  Characters.  External  Form.  1  he  j^ross  ajipcaiuiKe  ot  carci- 
nomas \aius  ^iiatl\,  l>iit  in  ;;iiuial  loilnws  one  of  three  types — the 
iiicciarix c,  thi-  noduhii,  ami  the  fun^itoini. 

Tht-  Ulcerativt'  i  l"i^.  'y4).  I  his  i\  |n-  arises  most  freciiicntiv  from 
surfaces  coN'ered  with  scjuamoiis  epithehum.     A  ^ood  example  is  rodent 


\/f 


W 


Carcinoma  of  lip.    Growth  of  cell  columns  is  more  advanced,  and  there  is 
round-celled  mfiltration. 

ulcer  of  the  face,  in  which,  beginning  from  one  pomt,  the  normal  epithe- 
lial surface  is  destroyed  as  the  cancerous  process  advances.  1  he  course 
of  destruction  resembles  in  principle  other  chronic  ulcerative  processes, 


Fig.  94 


--:'r* '--w 


■•^■iiW-^  ^*'* 


.^':-;;t 


,.;  ■     ■■  ...■■■   \  * 

Schematic  representation  of  ulcerative  carcinoma.     The  covering  skin  is  destroyed 

as  the  growth  advances. 

particularly  tuberculosis  and  syphilis.  Carcinomas,  however,  are  not 
ulcers  pure  and  simple,  for  the  peripheral  infiltration  leads  to  thicken- 
ing so  that  the  ulcer  has  a  raised  border.  When  the  growth  is  very 
active  and  the  deeper  tissue  is  invaded,  large  masses  ma\-  be  formed 
underlying  the  ulcer.  When  the  carcinoma  cells  infiltrate  the  surround- 
II 


162  CARCINOMA 

ing  tissue  extensivel}',  the  ulcer  forms  an  insignificant  part  of  the  tumor. 
Superficial  ulceration  with  borders  but  slightly  infiltrated  indicats  a  slow 
growth,  while  greater  infiltration  indicates  more  rapid  extension. 

Fig.  95 


''J: 

f; 

.-■— 

^.ffl 

;;^  ■ 

if.. 

.■!■■■/    ; 

'*'V 

\ 

Jjfi 

.''■^■^' 

'^\k??  :  '■■ 

v4/? 

■  V"; 

■'. ' 

'/:  ■ 

■  (:■% 

F   \ 


^_jw^  '; 


& 


Schematic  representation  of  a  carcinoma  of  the  mamma.    The  tumor  forms  a  nodular 
mass  mdependent  of  the  surface. 

The  Nodular  TFig.  95). — This  is  the  form  which  usualh"  arises  in 
the  centre  of  parenchymatous  organs.  In  slowh^  growing  carcinomas 
the  formation  of  fibrous  tissue  is  extensive,  and  the  tumor  becomes 
irregular  and  nodular  because  of  the  contractions  of  this  tissue.  If 
these    contracting    fibers    are    attached    directh^    or    indirectly    to    the 

Fig.  96 


■>t^- 


J.:/J  /  f^  ' 


Schematic  representation  of  a  deep   carcinoma  over  which  the  skin  has   ulcerated 

secondarily. 

surface,  they  produce  dimpling,  which  becomes  more  noticeable  if 
the  centre  degenerates.  The  more  rapidly  growing  types  compress  the 
surrounding  tissue  and  form  pseudocapsules  and  thus  resemble  in  their 
external  form  the  expansile  tumors.  When  such  carcinomas  approach 
the  surface  ulceration  may  arise  secondarily  (Fig.  96),  either  by  pressure 


I'llYSlC.II.  i-.ll.lR.ICTERS  OF  C.IRCISOM.I 


i(i;; 


necrosis  or  b\'  an  actual  extension  ot  the  malignant  cells  into  the  surface 
epithelium.  An  ini|')eiulinii  ulceration  of  the  surface  is  presa^ec^  b\' 
intense  Muiiiii  ot  the  skin,  due    to  iiuiiasecl  \  asculan/arion. 


Fk;.  97 


Mr 


■7;l 


;(^  U^i.'  /  ■  J  •'  '  ,-':,?■;";  ;^^^=#^^F^ 


J> 


Schematic   representation  of  an   intestinal  carcinoma,  forming   primarily   a   tumor 
projecting  into  the  free  lumen  of  the  bowel. 

The  Fungiform  (Fig.  97). — In  this  t^pe  the  mass  of  the  tumor  pro- 
jects outward  from  the  surface  from  which  it  arises.     In  externa!  form 


Fig. 


/^^%^ 


Pohp  of  intestine,  showing  prolifer.r     :  .,       d  cells.     The  basement  membrane 

is  intact. 


It  resembles  a   papilloma,  and  in   early  stages  it  is  only  b\"  examining 
the  base  for  signs  of  infiltration  that  it  is  possible  to  determine  its  malig- 


164  CARCINOMA 

nant  character.  The  surface  may  show  proHferation  (Fig.  98),  while 
the  deeper  portions  are  unaffected.  This  type  occurs  most  frequently 
on  mucous  surfaces,  notably  the  bladder  and  intestinal  tract.  Fungous 
tumors  may  form  secondarily  by  the  perforation  of  the  surface  by  deeply 
seated  tumors  of  the  nodular  type  and  the  growth  of  the  tumor  bej^ond 
the  surface  (Fig.  99).  These  are  nodular  tumors  primarily,  and  the 
fungous  development  is  but  an  accident  of  growth.  They  are  often 
seen  in  glandular  carcinomas  of  the  breast. 

Fig.  99 


:     ■''  •-;'  .  ■■   ■    -■"'    .  -'"l."^^' 


JP/ 


Schematic  drawing  of  a  breast  carcinoma  which  has  perforated  the  skm  and  formed 
secondarily  a  firm  fungous  mass. 

Macroscopic  Appearance  on  Section. — On  section,  carcinomas  are  grayish 
white  or  reddish  grav,  or  sometimes  translucent.  Parts  that  have  under- 
gone fatty  degeneration  are  deep  yellow.  One  can  usually  distinguish 
stroma  and  parenchyma  by  their  colors,  white  or  pink  and  grayish 
white  respectivel}^  In  the  more  cellular  types  the  surface  sometimes 
appears  moist,  grayish  white,  homogeneous,  and,  in  the  scirrhous  type, 
the  sparse  parenchj^ma  ma}^  be  distinguished  with  difficulty,  the  whole 
presenting  the  appearance  of  a  fibroma;  but  in  the  majority  of  cases 
the  contrast  is  so  plain  that  the  character  of  the  tumor  can  be  recog- 
nized with  certainty  by  inspection.  In  many  superficial  carcinomas 
the  cell  columns  can  be  seen  on  the  surface  about  the  edge  of  the 
growth  and  can  be  forced  out  by  gentle  pressure.  These  "plugs"  may 
be  regarded  as  the  macroscopic  units  of  carcinoma.  By  crushing  the 
columns  under  a  cover-glass  they  are  seen  to  be  made  up  of  groups 
and  whorls  of  epithelial  cells. 


MICROSCOPIC  STRl  CTlRi:  Oi    C.I  RCI  .\()\l  ,1  105 

Consistency.  CaicinoiiKis  an-  al\va\s  hard  to  tlic-  roiicli.  'l"lu-\-  can 
In-  lust  coinpaird  to  a  puce  of  luhhir,  r.  <;.,  tin-  hcc-l  of"  a  iiiI)1kt  hoot, 
with  small  nocliila  t  ions  hki-  thi-  siii  laic  of  a  }iiicii  pc-ar;  ot,  as  tin-  (ifnnaiis 
say,  like  (.lastic  cat  tila^c,  not  without  elasticity  ,  hut  still,  in  the  main, 
cpiite  finii  to  tlu-  touch.  This  piciiliar  (ieiisitv  in  cancer  is  remarkahh' 
constant.  It  differs  hut  little,  iiiispecri\e  of"  the  proportion  of  cells 
and  connective  tissue.  Tlu-  lar^e,  celluhii  tumors  are  hut  little  less 
firm  than  those  poor  in  cells.  C\st  formation  ma\  mask  the  consistency, 
and  dejienerative  processes  may  hrin<!;  ahout  a  change  in  consistenc\'  as 
IS  seen  m  colloid  carcinomas  of"  the  sromai'h  or  hreast.  In  the  higher 
t\pes  of  cancer,  the  consistency  of"  the  tumor  may  be  that  of  the  organ 
in  which  it  originates.  This  is  notable  in  some  fungoid  tumors  of  the 
intestinal  tract,  in  the  secondary  malignancy  in  goitre,  and  in  ovarian 
cystomas.  The  consistency'  in  these  cases  is  due  to  the  fact  that  a 
large  proportion  of  the  tumor  mass  is  relatively  normal  and  that  por- 
tion which  has  become  definitely  malignant  is  insignificant  compared 
with  the  tumor  as  a  whole.  Even  that  portion  which  is  malignant 
is  not  at  first  accompanied  b}'  a  proliferation  of  the  connective  tissue, 
but  when  such  tumors  develop  new  tissue  it  has  the  peculiar  carcinoma 
consistenc)-.  If  the  area  involved  in  the  change  be  palpated  it  is  easil\- 
recognized,  but  when  such  an  area  is  situated  in  the  interior  of  the  tumor 
it  may  escape  notice  until  a  section  is  made. 

The  term  "-encephaloid"  was  introduced  when  "cancer"  w^as  syn- 
onymous with  "malignancy"  to  designate  malignant  tumors  which  were 
brain-like  in  consistency'.  Such  tumors,  however,  are  realh'  sarcomas, 
as  histological  stud}'  shows.  The  term  has  been  retained  to  describe 
the  very  cellular  carcinomas,  even  though  the\'  are  not  brain-like  in 
consistency,  and  it  would  be  well  to  abandon  the  word  in  this  sense. 
Microscopic  Structure. — All  carcinomas  are  made  up  of  connective 
tissue  (stroma)  and  cells  (parench^'ma),  and  in  the  simplest  form 
(Fig.  lOo)  are  composed  of  groups  of  epithelial  cells  surrounded  bv 
connective  tissue;  but  the  mutual  relations  of  these  elements  are  often 
very  complex,  because  of  the  tendency  of  the  carcinoma  cells  toward 
invasion.  The  correct  determination  of  these  relations  is  of  greater 
importance  in  carcinomas  than  in  other  tumors,  because  upon  them 
depend  the  diagnosis  and  the  interpretation  of  the  life  history  of  the 
tumor. 

Connective  Tissue, — The  stroma  is  derived  from  two  sources:  (i) 
From  the  supportive  tissue  of  the  invaded  organ;  (2)  it  ma\'  be 
newdy  formed.  In  a  given  tumor  it  is  often  difficult  to  determine  the 
origin  of  its  stroma.  In  the  pedunculated  and  expansile  types  the 
stroma  is  all  newly  formed.  In  the  infiltrating  type  both  kinds  are 
present.     The    stroma    of    the    advancing    border    is    often    made    up 


166  CARCINOMA 

entirely  of  the  connective  tissue  of  the  organ  invaded,  but  new 
tissue  is  soon  formed  b}^  the  reactive  growth  of  the  old  fibrous  tissue, 
so  that  the  stroma  is  derived  from  both  sources.  Usually,  therefore, 
the  stroma  is  made  up  from  the  tissue  invaded  by  the  tumor  plus  that 
newly  formed  as  a  result  of  reactive  growth.  The  manner  in  which 
the  connective  tissue  is  produced  is  not  explained.  Klippel  and  Renend^ 
believe  that  the  connective  tissue  is  formed  from  the  round  cells  of 
the  blood  stream. 


Fig.  ioo 


'^iff 


Simple  carcinoma  of  mamma.      Connective  tissue  (stroma)  encloses  groups  of 
epithelial  cells  (parenchyma). 

The  presence  of  carcmoma  cells  m  connective  tissue  produces  various 
effects.  Some  cells  cause  hyperplasia;  others  leave  the  tissue  undis- 
turbed. The  cause  for  the  difference  is  not  known,  but  it  seems  to  lie 
in  a  specific  action  of  the  carcmoma  cells  upon  the  connective  tissue, 
and  not  in  the  character  of  the  connective  tissue  itself,  since  in  metas- 
tatic tumors  the  same  reactive  growth  often  occurs  as  in  the  primary 
tumor,  though  the  environment  may  be  different.  That  is,  a  tumor 
with  much  fibrous  tissue  will  form  metastases  which  also  tend  to  be 
fibrous;  but  this  is  by  no  means  constant.  On  the  contrary,  primary 
tumors  with  much  fibrous  tissue  may  form  very  large,  rapidly  growing 
metastases  with  very  little  connective  tissue.  When  a  secondary  tumor 
deviates  from  the  mother  type  it  nearly  always  shows  less  tendency 
to  stimulate  the  growth  of  fibrous  tissue,  which  indicates  in  a  general 
way  its  greater  malignancy.  Some  tumors  may  grow  too  rapidly  for 
the  connective  tissue  to  react,  or  the  toxicity  of  the  invading  cells  may 

^  Rev.  de  med.,  1907,  xxvii,  11, 


CELLS,   FORM     IM)  STRICT  I  RT  Ol'  C.I  RCl  \(f\l  .1 


•  i7 


liniijj;  about  tlu-  sanic  result,  just  as  in  ccitain  severe  intections  a  leuko- 
penia may  result  troni  the  failure  of  the  leukocytes  to  react.  I  he  fornia- 
tion  ot  hhious  tissui-  has  hciii  rti;ai(l((l  h\  some  as  a  conservative 
process,  an  attempt  to  wall  ott  the  tumor,  such  as  occurs  ahout  a  tuher- 
culous  focus.  As  a  matter  of  fact,  it  does  have  a  tendenc)'  to  lessen 
the  rate  of  siiowth.  This  is  best  seen  in  regional  metastases,  m  which 
an  ahumlance  of  newl\  formed  connective  tissue  surrounds  a  group 
of  epithelial  cells  which  are  undergoing:;  degeneration  'Pig.  lOi).  On 
the  other  hand,  the  presence  of  granulation  tissue  aids  extension,  and 
It  IS  tor  this  reason  that  tumors  treiiuently  spread  so  rapidly  after  a 
section    has    been    excised    for    diagnostic    purposes.       1  he    bloodvessels 

Fic;.  loi 


Cells  in  a  regional  metastasis  undergoing  degeneration. 


in  the  invaded  region  ma}'  undergo  various  alterations.  The  endothe- 
lium may  multipl\',  as  shown  b\-  the  presence  of  mitotic  figures,  and 
ma\-  take  part  in  stroma  formation;  ma\'  become  epithelioid  and  assume 
a  cuboidal  shape;  or  may  degenerate  and  atroph\'.  New  hmph  vessels 
are  not  formed. 

Cells,  Form  and  Structure. — There  is  no  specific  carcinoma  cell.  All 
carcinoma  cells  are  epithelial,  but  this  fact  is  often  not  apparent  from 
examination  of  a  single  cell  removed  from  its  environment.  It  is  only 
by  its  association  with  other  cells  that  we  are  enabled  to  recognize  a 
carcinoma  cell  as  such.  In  general,  the  more  rapidly  a  carcinoma 
grows  the  more  closeh'  its  cells  resemble  the  undiflerentiated  embr\onal 
cell. 


168  CARCINOMA 

The  form  of  the  cell  in  any  given  carcinoma  depends  upon  two  factors: 
(i)  The  degree  of  metaplasia  which  the  cell  has  undergone;  (2)  condi- 
tions external  to  the  cell.  Thus,  some  cells  resemble  closely  the  cells 
of  the  mother  tissue,  e.  g.,  there  are  carcinomas  of  the  intestine  and 
uterus  with  cylindrical  cells,  of  the  thyroid  with  cuboidal  cells,  of  the 
Hver  with  hver-like  cells.  In  such  cases  the  tissue  of  the  carcinoma 
not  only  resembles  the  mother  tissue,  but  may  assume  its  function 
more  or  less  perfectly.  Secretions  may  be  formed  within  glandular 
carcinomas,  and  extensive    tumors    of   the    thyroid    and    adrenals    may 


Fig.  102 


JS 

1 

\ 

S'    "{ 

■',.% 


\.j;.m' 


/  '' 


r' 


<3 


'■li; 


V. 


.'</"•;•?•.%;.•  r.. . -^i  .oi'.?-f 


Epithelioma,  showing  loss  of  cell  prickles.     They  are  present  in  the  upper  part  of 
the  figure,  but  absent  below. 

completely  destroy  those  glands  without  giving  rise  to  the  constitu- 
tional disturbances  which  ordinarily  take  place  when  these  glands 
are  out  of  function.  More  often  the  reversion  of  the  carcinoma  cells 
is  such  that  they  do  not  imitate  the  formation  of  the  mother  cells  and 
are  incapable  of  imitating  their  function. 

When  carcinoma  cells  which  have  deviated  from  the  normal  are 
closely  studied,  very  complex  conditions  are  encountered.  Usually,  the 
earhest  change  noticed  is  in  the  cytoplasm,  which  becomes  granular; 
then  the  external  form  changes;  prickle  cells,  for  example,  lose  their 


CELLS,   lORM     IM)  STMICTt  ML  OF  C./ RC/ \0.\LI 


109 


spines  antl  Uc-conu-  coliiiiinai  or  s|>luiual  il'iji.  I02j.  Diimi^  the  (.-aily 
(.haiims  in  tlu-  c\  roplasin  rhi-  luulci  itsi-nihU-  rhost-  ot  rlu-  niorlici'  cells, 
hill  quukK  ilu\  too  show  inipoitant  dcx  la  t  ions.  I  he  details  ot  these 
iail\  eliaimes  ha\e  not  lueii  liilh  woikeci  out,  luit  it  lias  iieen  noticed 
rliat    tin     chioniosoinis    \ai\     m    luiinlni    and    character    and    that    tn- 


Imc.  103 


Ik;.  104 


;fP\ 


1  npoLir  iiiiroses  in  isolatt-d  carcinoma 
cells. 


Imperfect   division  of  chromosomes 
in  isolated  carcinoma  cells. 


polar  or  multipolar  mitoses  sometimes  occur  (Fig.  103).  In  certain 
types  of  cell  changes,  apparentl}'  degenerative,  the  chromosomes  fail  to 
separate  normally  (Fig.  104).  Hansemann'  has  made  these  abnormal 
mitoses  objects  of  minute  study,  and  has  come  to  the  conclusion   that 


Fig. 


10: 


aa  - 


®  «  o  ^  «  »  "»*  »  *  ©  « 


Cells  from  the  border  of  a  rapidly  t;ro\vmg  breast  carci 


noma. 


it  is  due  to  them  that  new  races  of  cells  are  developed.  My  own  studies 
in  early  epitheliomas  of  the  skin,  in  A.-ray  carcinomas,  and  in  artificial 
epithelial  proliferations  have  convinced  me  that  the  primary  changes 
occur  in  the  cytoplasm  and  that  abnormal  mitoses  appear  only  after 
the  cytoplasm  has  attained  a  certain  degree  of  deviation.     In  the  more 


'  Ztschr.  f.  Krebsforsch.,  1907,  v,  510. 


170  CARCINOMA 

advanced  degrees  of  deviation,  the  cells  lose  all  resemblance  not  only 
to  their  mother  cell,  but  to  all  epithelial  cells,  and  it  is  only  by  their 
relation  to  the  connective  tissue  that  their  character  and  origin  can 
be  determined  (Fig.  105). 

The  Topographical  Relation  of  Cells  and  Connective  Tissue. — A  microscopic 
section  of  a  typical  carcinoma  shows  groups  of  cells  surrounded  b}^ 
connective  tissue  (Fig.  106).  These  are  the  "cancer  nests"  which  have 
played  such  a  prominent  part  in  the  discussion  of  the  histology  of  car- 
cinoma. It  was  the  formation  of  these  nests  that  was  formerly  regarded 
as  evidence  of  malignancy,  for  it  was  assumed  that  they  resulted  from 
the  escape  of  cells  from  the  central  group  and   the  formation  of  new 

Fig.  106 


a 


C^-—.'^ ;r^:v-': 


/-••     ^  '.• 


-  ^    '"      1 

■'j^-'^ 

•  "  i-i'  "■ 

,7;V--' 

■  '  y.  ".'■. 

iSv! 

■     "^•,-<? 

'"^•Mv.- 

—^%a 

0/  ,'■ 

r  ■■;:' ,' 

•  f-      r     / 

•    ^v^;;„,> 

•' J>     ■' 

r-^     ,  ^ 

■'f  "} 

■,    :-^'" 

:    '--V 

6 


tX^-. 


:,  S 


Carcinoma  simplex:    a,  carcinoma  cells;  b,  connective  tissue;  c,  round-celled 
infiltration  in  connective  tissue. 

groups  at  some  distance  from  the  primary  tumor  mass.  The  study 
of  serial  sections  and  reconstructions  of  small  tumors  has  shown,  how- 
ever, that  the  formation  of  "nests"  is  almost  always  only  apparent. 
The  growth  branches  out  like  the  limbs  of  a  tree,  and  a  single  cross- 
section  shows  these  as  isolated  groups  of  cells,  the  connection  with  the 
rest  of  the  tumor  falling  outside  the  plane  of  the  section  (Fig.  107). 
Many  tumors,  however,  support  the  older  view,  for  cells  may  escape 
from  the  border  of  the  tumor  into  the  spaces  of  the  connective  tissue 
and  become  independent  of  the  mother  tumor,  forming,  in  fact,  a  regional, 
metastasis.  A  section  through  such  a  group  of  cells  shows  a  true  cancer 
nest  according  to  the  old  view  (Fig.  108).  Serial  sections  alone,  in  most 
instances,  make  it  possible  to  determine  which  type  is  present. 


Tor(jc.k.iriiu:.ii.  ki:i..iri<).\  ui  cells  .jmj  co.wlct/il  t/ssi/-:    171 

In    soiiK-    iiistancts    cpirlulial    ctlls    may    Ik-    cliff"ustl\     distributed    in 
flu-  coniucrnc   tissue  so   that  tath   cell   is   more  or   less  surrounded    h\ 


C 


r  k;.  107 


/*,. 


I' 


■f.,.. 


M 


-  y.?  •• 


^' 


Schematic  drawinji  of  a  carcinoma,  showing  how  a  section  in  Hne  a-b  would  show 
apparent  cell  nests,  while  really  the  cell  columns  are  cf)nnected  with  the  main  portion 
of  the  tumor. 


Fig.  108 


a 


Jfi- 


Schematic  section  of  carcinoma  in  which  cells  have  escaped  from  the  periphery- 
forming  isolated  nodules.  A  section  a-h  made  through  these  nodules  shows  true  nests 
unconnected  with  mam  rumor. 


connective-tissue   Hbrils   (Fig.    109),   presenting  somewhat   the  arrange- 
ment topical  for  sarcoma.     Not  infrequently  small  areas  about  advanc- 


172  CARCINOMA 

ing  carcinomas  have  this  arrangement,  and  occasionally  it  is  found 
throughout  the  major  portion  of  tumors  which  are  unquestionably  of 
epithelial  origm. 

Fig.  109 


V 


) 


:..  fey    ^^a     vJn        ,    te  'o  ^   >  vi' 


\ 

\  . 

X 

\ 


''.V© 


t-) 


i  \ '% 


\'' 


''■"'  'w<    ^^.r-  ft'  ,.:\^    ^^  ^ 

Carcinoma  of  the  mamma  cells  scattered  diffusely  throughout  the  connective  tissue. 

Relation  of  Cells  and  Stroma. — The  relation  of  cells  and  connective 
tissue  has  been  considered  in  the  section  on  etiology.  Our  interest 
centres  here  not  in  a  causal  but  in  a  developmental  problem;  whether 
the   entire   stimulus   to   growth   lies   in   the   epithehum   or  whether   the 

Fig.  1 10 


c  ah 

Epithelium  lining  an  ovarian  cyst:     a,  h,  cells  piling  up  without  connective  tissue; 
c,  fine  strands  of  connective  tissue  follow  the  cells,  but  no  vessels. 

connective  tissue  takes  an  active  part.  In  certain  tumors,  especially 
in  ovarian  cysts,  epithelial  cells  develop  without  the  presence  of  con- 
nective tissue  (Fig.  no).  This  has  been  regarded  as  evidence  that  the 
epithelium  is  the  active  factor  and  that  the  connective  tissue  is  secondary. 


SKCO.yn.iRV  cii.ixcks  i\  c.ircimjm./ 


173 


( )ii  tin-  Dtlur  IkiiuI,  it  is  ;i  laot  tli;it  m  m;in\  taiciiiDiiKis,  tin-  coniuctive- 
tissui-  |")i()iliKti()n  IS  far  iii  c-\ocss  ot  t he- ipirlulial  |)i<)ciuiti()iK  :iiul  even 
if  stiiiuilarcii  h\  tin-  (.iMtiu-liuiii  ir  at  least  ^aiiis  a  niomtiuiim  winch 
ir  iiiaiiuains.  Soim-  luu  ami  intcitsriiif;  observations  havt-  hc-c-ii  maclc- 
in  iiiousc  carcinomas.  In  some  ol  these,  after  a  tew  generations,  the 
connective  tissue  becomes  greater  and  the  epithelium  becomes  less 
until  the  entire  tumoi-  is  made  uji  ot  (.-mbr^'onal  connective  tissue;  in 
other  wortls,  a  sarcoma  has  de\iloped.  I  he  changes  which  rake  jilace 
in  mouse  tumors  strengthen  the  assumption  otten  made  that  connec- 
tive tissue  limits  the  tievelopment  of  epithelium  and  in  those  tumors 
where  rlu  comucrne  tissue  becomes  acti\e  the  epithelial  cells  dis- 
appear. I  mctorial  chemistry  which  might  gi\e  some  evidence  has 
not  yet  been  applied  to  this  problem. 


Fig.  1 1 1 


-■V  .-* 


'■A         M 


/// 


Cells  in  scirrhous  carcinoma  of  the  breast  becommo;  fused;  the  cell  boundaries  are 
indistinct,  and  the  nuclei  deiienerated. 


Secondary  Changes. — Atrophy  (Fig.  iii). — Atrophy  from  lack  ot 
nutrition  occurs  especialh'  where  there  is  contraction  ot  the  connective 
tissue  with  obliteration  or  partial  occlusion  of  the  vessels.  It  is  often 
accompanied  by  karyorrhexis  and  chromatolysis.  In  tumors  made 
up  largely  of  fibrous  tissue  it  has  been  assumed  that  cells  in  greater 
number  were  at  one  time  present,  but  that  the}'  perished  from  lack  of 
nutrition.  The  presence  of  fat  in  the  protoplasm  which  so  often  accom- 
panies atrophy,  and  the  changes  in  the  nucleus  already  mentioned, 
make  this  seem  probable. 

Calcareous  Infiltration. — Epithelium,  especiall\-  horny  portions,  and  also 
stroma   ma\-  calcif\',  following  h\aline  degeneration.       Limited  necrotic 


174  CARCINOMA 

areas  are  usually  most  prone  to  calcification.     On  the  whole,  it  is  one 
of  the  rarer  forms  of  secondary  changes. 

Fatty  Metamorphosis. — This  form  of  degeneration  is  extremely  common, 
especially  in  rapidly  growing  tumors.  Such  tumors  often  show  on 
cut  surfaces  fine  lines  of  yellow  material  which  represent  degenerated 
columns  of  cells.  Frozen  sections  stained  with  Sudan  III  show  these 
changes  strikingly. 

Fig.  112 


M 


i^^y , 


a 


C-:^ 


Necrotic  lymph  gland  in  a  non-degenerated  carcinoma  of  the  breast:  a,  connective 
tissue  with  round-celled  infiltration;  b,  carcinoma  cells;  c,  degenerated  carcinomatous 
area. 

Necrosis  (Fig.  112). — Necrosis  as  it  occurs  in  granulomas  is  also 
seen  in  carcinomas,  especially  in  the  rapidly  growing  pseudoencapsu- 
lated  type,  and  it  may  be  due  to  occlusion  of  vessels  by  thrombosis  or 
to  suppuration  following  secondary  infection.  This  accident  is  most 
likely  to  occur  in  situations  normally  exposed  to  bacteria,  as  in  the 
digestive  tract  or  the  cervix.  The  series  of  phenomena  which  usually 
follows  infection  occurs  here  in  so  far  as  the  tissue  will  permit;  and, 
because  of  the  relatively  defenceless  character  of  the  tissue,  necrotic 
sloughs  are  frequent.     The  absorption  of  toxic  material  from  this  source 


SKC(J.\I).IR)    CII.IM.ES  IS  (:,lki:i.\(jM,l  17.') 

adds  nuicli  to  tin-  hiiidi  n  of  tin-  |):iti(nt.  As  the  de^cnc'r:ii  ion  pioj^resses, 
N'fsscls  bttoim-  tiotlcd  ;ind  r.\ttn.si\ c  lunioiih.i^cs  into  ilic  rumor  or 
externall\  oiiui.  In  tins  \\:i\-  cysts  ni;i\  toiin,  tlu-  loiuciits  of  which 
vaiy  HI  i-oloi  lioni  daik  icd  to  h^ht  stiavv,  dc-pciidni^  n|)on  thi-  dc-^it-c- 
to  which  tht'  hcmo^lohm  is  ahsoihcd.  C'holcstciin  ci\stals  usiialK' 
remain  to  nuhcatc  the  ()ri<i,in  of"  the  c\st.  If  the  hemorrhage  takes 
place  e.\rt.rnail\  ,  iih-  may  he  directly  endanj^ered.  The  necrotic  area 
is  ^ray,  homogeneous,  and  often  soft.  ihe  microscopic  section  shows 
granular  debris  which  does  not  stain.  About  the  border  or  along  vessels 
there  may  be  extensive  round-celled  infiltration,  and  along  the  vessels 
where  nutntion  is  maintaiiutl,  carcinoma  cells  ma\'  maintain  rheir 
\italiry. 

Hydropic  Degeneration.  This  condition  is  characterized  by  the  collec- 
tion of  droplets  of  fluid  in  the  protoplasm  or  nuclei  of  the  cells.  The 
cytoplasm  may  swell  up  and  appear  to  efface  the  cell  boundaries. 

Fig.  113 


•^'     Q     - 


.   3    J       , 


a 


'  )    • 

-^sv^-- 

% 

X   1  < 

•'•'. 

,      3     O. 


,  'S- 

Colloid  carcinoma  of  stomach:     a,  colloid  material;  h,  carcinoma  cells  near  vessels 

have  escaped  defjeneration. 

Colloid  Degeneration. —  Ihis  type  occurs  usually  in  glandular  tumors, 
and  may  attect  both  stroma  and  parenchyma.  Cells  become  filled 
w^ith  colloid  material  which  tends  to  swell,  thus  pushmg  the  nuclei  aside 
and  causing  the  alveoli  to  appear  large  and  round  (Fig.  113).  The 
cells  ma}'  finally  burst  and  mucin  maA'  collect  in  the  lumen  or  among 
the  cells  if  there  is  no  lumen.  The  nuclei  finalh'  break  up  and  remain 
as  fragments  enclosed  by  columns  of  the  colloid  material.  The  stroma 
does  not  become  colloid,  but  imbibes  fluid,  so  that  the  fibers  are  spread 
apart.  Large  areas  may  be  so  extensively  changed  that  the  character 
of  the  tumor  can  scarcely  be  recognized.  Metastases  from  such  tumors 
often   show   similar   degenerations.     The   tumor  which    has   undergone 


176  CARCINOMA 

this  degeneration  is  soft,  semifluctuating,  and  bluish  or  grayish  white 
in  color.  Cells  about  the  border  of  alveoli  nearest  the  blood  supply 
may  maintain  their  integrity  when  all  others  are  degenerated, 

Cornification. — Horny  formation  occurs  especially  in  carcinomas  of 
the  skin,  but  it  may  be  found  in  any  region  covered  with  squamous 
epithelium. 

Hyaline  Degeneration. — This  occurs  in  two  forms — small  or  large 
round  transparent  homogeneous  droplets  m  the  cytoplasm  or  nucleus; 
or  the  whole  protoplasm  may  degenerate  to  a  homogeneous  mass  which 
shows  a  certain  affinity  for  acid  aniline  stains.  These  cells  tend  to  pack 
together  and  form  la^^ers. 

Constitutional  Effects. — Causes  of  Death. — The  manner  in  which  car- 
cinoma affects  the  body  as  a  whole  is  a  complex  problem.  Cachexia,  the 
general  expression  for  the  constitutional  effect  of  carcinoma,  is  marked 
by  a  dull,  muddy  yellow,  inelastic  skin,  and  a  dull,  lusterless  eye. 
The  cause  of  this  profound  effect  has  not  been  satisfactorily  explained, 
but  it  probably  is  due  to  some  product  of  carcinoma-cell  metabolism, 
though  no  specific  toxin  has  been  identified.  The  chief  argument  in 
favor  of  this  view  is  that  cachexia  may  appear  m  cases  where  there 
is  no  ulceration  or  other  obvious  source  of  mtoxication,  nor  interfer- 
ence with  the  general  nutrition.  After  ulceration  and  the  associated 
infection  intervene,  the  condition  becomes  more  complicated  and  these 
later  factors  probably  combine  to  produce  the  total  deleterious  effect. 
Suppuration  is  in  many  instances,  no  doubt,  the  predominating  factor. 
The  amount  of  nutrition  actually  withdrawn  from  the  body  by  the 
tumor  is  often  insignificant,  but  when  a  tumor  is  so  situated  as  to  inter- 
fere with  the  taking  or  assimilation  of  food  it  seriously  affects  nutrition. 
When  the  ulceration  invades  a  large  bloodvessel,  e.  g.,  in  the  stomach 
or  uterus,  hemorrhage  is  likely  to  play  an  important  part  toward  pro- 
ducing cachexia. 

The  effect  on  the  body  is  pathologically  that  of  a  secondary  anemia, 
or  the  blood  may  show  the  picture  of  pernicious  anemia.  The  erythro- 
cytes show  various  abnormalities;  poikilocytes,  microcytes,  megalo- 
cytes,  and  even  megaloblasts  have  been  noted,  and  the  color  index  is 
reduced.  Frequently  there  is  a  moderate  leukocytosis,  ii,ooo  or  12,000 
leukocytes  being  common.  If  there  is  a  complicating  mixed  infection 
the  leukocytes  may  correspond  to  the  infection  and  the  polynuclear 
cells  predominate,  if  indeed  the  body  is  able  to  react  at  all. 

Interference  with  alimentation  and  assimilation  and  the  systemic 
intoxication  cause  rapid  loss  of  weight,  which  becomes  one  of  the  most 
prominent  terminal  symptoms.  It  is  evident  that  the  toxemia  affects 
the  digestive  functions  directly,  since  these  disturbances  occur  irrespec- 
tive of  the  situation  of  the  tumor. 


cjRuiirn  J.\D  DissKMi.\.irin\  or  c  ik(:i\()\i.i  177 

Thf  ttiiiiiiial  stages  of  caicinoiiia  may  assiiim-  \ari()iis  aspects.  I  he 
erosion  ot  a  \tsstl  of  coiisidiiahK-  si/.c  ma\  lause  death  in  a  short  time 
bv  exsarifiuinatioii;  oi  upeatetl  small  In  iiioi  rliajies  may  pase  the  wa\' 
tor  some  fatal  intiixuiunt  disease.  Death  ma\  In-  due  to  malnutri- 
tion or  actual  srai\ation  if  the  stomach  is  the  seat  ot  the  tumor,  or 
from  intestinal  obstruction  it  the  intestine  is  the  region  diseased.  .An 
ulceiati\e  piociss  ma\  piiinit  tin-  extension  of  micctioii,  as  into  the 
mediastinum  in  esophageal  carcinoma  or  an  ascending  pyelonephrosis 
in  bladder,  rectal,  or  uterine  carcinoma.  When  the  growth  is  in  the 
upper  iespiiat()i\  tract  pneumonia  is  often  the-  terminal  result.  I  he 
direct  <ii()\\rh  ot"  the  tumor  may  cause  death  h\  (lisiilacinji  gradually 
the  available  area  in  any  organ  necessar\'  tor  the  maintenance  ot  life, 
for  example,  in  lung  or  brain.  In  many  instances,  pain  and  the  conse- 
(luent  loss  of  sleep,  together  with  malnutrition,  so  reduce  the  patient 
that  very  sHght  disease  in  an  organ  may  be  sufficient  to  cause  death, 
t\  g.,  a  slight  hypostatic  pneumonia,  an  acute  nephritis,  or  an  exacerba- 
tion of  a  chronic  nephritis.  Even  these  symptoms  may  be  lacking  and 
the  general  term  "exhaustion  "  ma\'  be  required  to  designate  the  imme- 
diate cause  tor  death. 

Growth  and  Dissemination. — It  was  formerly  believed  that  carci- 
nomas might  begin  at  several  points  simultaneously,  and  that  they 
develop  by  the  transformation  of  normal  into  malignant  cells  by  a  kind 
of  contagion.  This  question  has  already  been  discussed  in  connection 
with  the  growth  of  tumors.  It  remains,  however,  to  call  attention 
again  to  the  manner  of  local  extension  about  the  tumor.  Cells 
push  out  from  the  neoplasm  either  in  a  continuous  column  main- 
taining connection  with  the  main  body  of  the  carcinoma,  or  cells  may 
extend  be\'ond  the  advancing  column  and  by  proliferating  form  a  new 
tumor  independent  of  the  primar}'  tumor  ^et  in  its  immediate  vicinity. 
It  is  often  difficult  in  studying  tumor  sections  to  determine  if  a  group 
of  cells  is  a  part  of  an  independent  nodule  or  a  section  of  a  branch  trom 
the  main  growth.  As  a  rule,  serial  sections  alone  are  able  to  decide 
this  point. 

It  is  often  possible,  particularly'  when  a  carcinoma  invades  a  muscle, 
to  trace  the  cell  columns,  single  file,  for  a  long  distance  into  the  sur- 
rounding tissue.  The  question  of  local  metastasis  has  an  important 
bearing  upon  the  question  of  recurrence  after  operation.  Local  recur- 
rence when  the  primary  excision  was  made  wide  of  the  tumor,  as 
demonstrated  by  examination  of  its  border,  implies  that  there  have 
been  local  metastases  be\ond  the  confines  of  the  tumor  and  beyond  the 
lines  of  excision,  or  that  a  carcinoma  similar  to  the  primary  one  has 
arisen  de  novo  in   the  same  region.     The  former  is  the  more  probable. 

Wh}-  such  long  intervals  intervene  between  the  removal  of  the  primary 

12 


178 


CARCINOMA 


tumor  and  the  appearance  of  the  secondary  tumor  lacks  satisfactory 
explanation.  Incision  into  the  primary  tumor  is  often  followed  by  a 
greatly  increased  growth  and  disposition  to  metastasis,  either  because 
of  the  formation  of  a  suitable  medium  for  growth  or  by  opening  tissue 

spaces  to  invasion.      It  might  be 
^^^-  ^^4  expected  that  islands   allowed  to 

.-     ,        .  ^  remain  after  excision  of  the  main 

tumor  would  show  this  disposi- 
tion. That  they  do  not,  allows  us 
no  other  interpretation  than  to 
assume  that  the  system  when  rid 
of  the  main  tumor  is  able  to 
com.bat  successfully  for  a  time 
the  small  portion  remaining. 
There  is  some  evidence  to  sup- 
port such  a  view.  Certain  tissues 
repel  the  invasion  of  carcinoma. 
Advance  of  the  tumor  often  halts 
sharply  when  an  area  of  muscle 
(Fig.  114)  or  a  fat  lobule  (Fig. 
115)  is  encountered.  It  is  interesting  to  note  that  these  tissues  are  not 
able  to  institute  the  processes  of  wound  healing  with  the  facility  of 
other  tissues.      When  malignant  cells  do  invade  them  it  is  along  channels 


...J) 
lb 


Edge  of  a  mammary  carcmoma  about  to 
invade  the  pectoral  muscle:  a,  advancmg 
cell  column;  b,  muscle  fibers. 


Fig.  115 


o 


i'fr   -O 


Edge  of  a  large  mammary  carcinoma:    a,  carcinoma  cell  nests;  b,  fat  cells. 


provided  with  connective  tissue.  Bone,  too,  is  rarely  invaded;  in  fact, 
the  medullary  cavity  alone  is  ever  affected.  When  carcinoma  develops 
in  the  region  of  bone  there  is  often  a  reactive  production  of  osseous 
tissue  (Fig.  116). 


M/rr.isT./s/s  179 

Metastasis.  Local.  \\  In  ii  rlu-  cells  txttnd  our  from  the  mother  tumor 
they  nia\  lomi  iiocliiK  s  \\  huh  ;m  nor  connected  with  the  orif^inal  tumor, 
but  are  m  its  ininuihate  \icimr\  .  liorsr  has  called  rhese  "local  meras- 
rases"  in  conriadisnncrion  to  re^iional  nutasrases  in  winch  rlu-  cells 
have  rravelled  some  disrance  hetore  tormln^  a  new  nodule.  I  lure  is 
ofren  no  sharp   dividing   line   herween  rhe  rwo. 

Regional.  —Extension  is  usually  alonjj;  rhe  lyni|>hatics,  and  ir  is  not 
uncommon  to  Hnd  growing  nodules  within  the  walls  of  a  lymph  channel. 
Sometimes,  as  in  the  lungs  or  peritoneum,  the  lymphatics  ma\'  he  filled 
with  columns  of  cells,  so  rhar  rhe  vessel  nerwork  srands  our  prominenrlw 
rile  rhoracic  ducr  especiall)  may  he  Hlled  in  rhis  \\a\'.  UsualK  rhe 
cells    are   carneil    alonji;   in    rhe    lynijih    current    unnl    a    hmph    gland    is 

Fig.  1 16 


C 


m./:: 


■:'  fH": 


Carcinoma  nodule  extending  into  the  periosteum:     a,  carcinoma;  h,  newly  formed 
bone;  c,  connective  tissue;  d,  bloodvessel. 

reached,  where  the\'  develop.  Somenmes  the  first  gland  escapes  and 
a  more  distant  gland  is  afFecred.  Whether  the  wandering  cells  are 
filtered  through  the  first  gland  or  are  detoured  rhrough  some  anasro- 
mosing  channel  is  not  known. 

Secondar}-  growths  in  general,  imitate  the  mother  tumor  more  or 
less  closeh'  (Fig.  117).  Thus,  pearls  may  be  formed  where  the  primary 
tumor  is  an  epithelioma  (Fig.  118),  or  the  glandular  structure  may  be 
retained  when  the  primary  tumor  is  an  adenocarcinoma  (Fig.  119). 
In  general,  the  cells  of  a  metastatic  tumor  are  of  a  lower  order  than 
those  of  the  primary  tumor.  The  metastatic  nodules  are  usually  spherical 
when  occurring  in  regions  where  resistance  is  equal  m  all  directions. 
This  is  seen  most  typically  in  the  liver.     There  is  often  a  sharp  line 


ISO  CARCINOMA 

of  demarcation  between  the  tumor  and  the  parenchyma  of  the  organ 
(Fig.  120). 

Fig.  117 


-^ ;  J> 


'.  V 


Metastasis  from  tongue  carcinoma  in  lymph  gland,  showing  islands  of  squamous 
epithelium  in  the  lymphoid  tissue. 

The  question  of  metastases  is  practically  the  most  important  one,  as 
it  is  they  that  frustrate  the  majority  of  attempts  at  cure.     The  site 

Fig.  118 


0      '^pt 


- 

\    -1 

>.    "  * 

' 

^i' 

1 

1 

..  'V,. 

V 

/ 

..•  'Y- 

: 

- 

y        " 

y. 

i, 

". 

» 

'■^ 

^    '     .0 

_ 

.-  ^•^'^ 

>'^  ft?-.. 

.^^=p<^ 

IcH    -n^^^iWS 


Pearl  in  lymph  gland.     Metastasis  from  a  carcinoma  of  the  lip. 

of  the  earhest  metastases  has  been  carefully  worked  out  for  the  carci- 
nomas of  the  various  important  regions,  and   may  most  profitably  be 


M /■:/-./  ST./ s/s 


Isl 


iliscussiil  m  tlu  lonsiilci  ;i  I  Kin  ol  those  itjiKJiis.  It  is  sufliiunr  to  sa\ 
in  this  pi. Ill-  th;it  (..i i (.imiiii.is  \;ii\  in  thc-ir  dispf)siti()ii  to  loiiii  iiH-r:is- 
rasfs.      In  .1  hiii.ul  \\.i\    those  iii  whirh  n  Ik  di  \iai(    most  lioni  the  niotlu-r 

!•  ic.  I  \') 


-^  , 


..,r*'t5 '"■■*"'*<>• 


-       ".-Off 


Oorf> 


^    . 


J> 


:%"..    —i 


'0»  ft 


Osfl' 


<•■- 


— r 


Columnar-celled  metastasis  in  liver  from  carcinoma  of  the  stomach:     a,  metastatic 
gland  cells;  b,  liver  epithelium;  c,  connective  tissue. 

Fig.  I20 


Metastatic  nodule  in   liver,  showing  boundary  between  glandular  caicinoma   aiiil 

liver  tissue. 


182  CARCINOMA 

type  are  most  apt  to  form  early  metastases,  and,  on  the  other  hand, 
the  less  the  deviation  the  less  the  disposition  to  metastatic  formation. 
For  example,  the  glandular  tumors  are  the  least  apt  to  form  metastases. 
This  is  not  universally  true,  however,  for  the  basal-celled  epitheliomas, 
which  bear  little  resemblance  to  the  epidermal  cells,  are  not  prone  to 
form  metastases.  Those  which  show  a  proneness  to  secondary  changes 
are  less  apt  to  form  metastases.  This  is  particularly  true  of  those  which 
undergo  colloid  degeneration.  If  the  abundant  formation  of  fibrous 
tissue  is  a  conservative  process,  as  some  pathologists  affirm,  tumors 
characterized  by  the  formation  of  much  stroma  should  show  less  tend- 
ency to  the  formation  of  secondary  tumors. 

Systemic. — The  bloodvessels  are  sometimes  the  avenues  of  dissemina- 
tion. The  cells  may  reach  them  through  the  thoracic  duct,  hence 
into  the  venous  circulation,  or  may  penetrate  directly  into  a  vein, 
or  more  rarely  into  an  artery.  The  carcinoma  may  gain  access  to 
the  bloodvessels  by  way  of  the  lymphatics  of  the  vessel  wall,  thence, 
by  extension,  into  the  lumen  of  the  vessel.  When  extension  takes 
place  by  way  of  the  bloodvessels  any  part  of  the  body  may  be 
invaded,  but  especially  the  lung,  liver,  bones,  nerve  centres,  and  the 
skin.  The  reason  for  this  predilection  of  secondary  growths  is  not 
understood.  It  is  likely  that  suitability  of  soil  is  a  more  important 
factor  than  accessibility,  for  certain  kinds  of  carcinomas  have  regions 
of  predilection  of  their  own.  Probably  those  cells  which  lodge  in  un- 
suitable soil  are  destroyed,  while  those  which  are  deposited  in  a  more 
suitable  medium  develop.  As  an  example,  multiple  nodules  ma}^  occur 
in  the  skin  and  the  remainder  of  the  body  remain  free. 

When  migrating  cells  reach  favorable  soil  other  than  the  lymph 
glands  (liver,  lungs),  they  usually  grow  rapidly,  with  a  disposition  to 
form  globular  expansile  tumors.  It  is  exceptional  for  such  metastases 
to  retain  with  any  degree  of  perfection  the  mother  type  of  cell,  though 
they  sometimes  do  so  in  a  striking  manner. 

Types  of  Carcinoma. — For  the  purpose  of  stud}^  it  is  sufficient  to 
classify  carcinomas  according  to  the  cells  from  which  they  spring. 
Thus  they  may  be  divided  into  the  squamous  and  columnar-celled 
types.  Variations  of  the  cells  of  these  groups  give  rise  to  modifica- 
tions in  tumor  types  which  some  writers  express  by  more  complicated 
classification,  but  this  simpler  classification,  adopted  by  Borst,  has 
much  to  commend  it. 

Squamous-celled  Carcinoma. — Carcinomas  derived  from  the  squamous 
cells  have  different  characteristics  according  to  the  situation  from 
which  they  spring.      It  is  convenient  to  separate  them  into  groups. 

Epidermoid  Type  (Fig.  121). — The  squamous  epithelium  of  the  skin 
gives    rise   to    tumors   which    have    a    disposition    to   slow   growth    and 


SQUAMOUS  CELLED  CIRCI \()M ,1 


183 


relativtlv    late    iiutastasis.        riu'se    biolofiical     characteristics    express 
themselves  histoloj^ically  hy  an  approach   to  the  normal  development  of 


P"lG.   121 


at* 


{^■^ 


'/  v^  ..-V 


/^.■;. 


/  ^  i  \ 


■;.^-  ^  V 


Carcinoma,  epidermoid  type. 


Fig.  122 


.  i  5«  .*  i  »i 'tiJ^'V- 


5P^ 


Epithelial  pearls. 


184  CARCINOMA 

epidermal  epithelium  resulting  in  the  so-called  pearly  formation  (Fig. 
122).  These  pearls  are  groups  of  cells  arranged  concentrically,  which 
present  progressive  changes  from  the  periphery  toward  the  centre, 
corresponding  to  the  changes  in  the  normal  epidermis  from  the  deep 
layers  to  the  surface.  They  are  striking  objects  when  seen  in  stained 
sections,  because  of  their  affinity  for  acid  d^'es.  They  obtain  their 
name  from  their  bluish-white,  glistening  appearance  in  unstained  sec- 
tions. In  teased  specimens  they  are  seen  to  be  made  up  of  irregular 
spindle-form  cells  with  large  ovoid  nuclei  surrounded  bv  a  structure- 
less protoplasm  (Fig.  123)  which  has  a  marked  affinity  for  acid  dyes. 
The  disposition  to  pearl  formation  is  often  seen  in  metastases  in  the 

Fig.  123 


Ci, 


'■**>    z 


•%' 


'9       ^,,V     ^  ^^4 


& 


Teased  pearl,  showing  forms  of  individual  cells. 

lymph  glands.  Carcinomas  which  develop  elsewhere  form  metastases 
in  the  skin  relatively  late.^  Epidermal  tissue  in  abnormal  situations, 
as  m  dermoids  and  teratomas,  occasionally  gives  rise  to  carcinoma. 
Not  mfrequently  persistent  gill  clefts  are  the  starting  point  of  such 
tumors.  Tumors  of  this  t^'pe  are  sometimes  found  where  the  presence 
of  squamous  epithelium  cannot  be  accounted  for  even  on  the  theory 
of  congenital  displacements.  That  they  result  from  metaplasia  from 
columnar  cells  seems  then  to  be  the  only  explanation.  This  explana- 
tion is  accepted  by  all  pathologists  for  such  tumors  in  the  gall-bladder, 
and  those  in  the  breast  and  stomach  may  belong  to  this  class. 

^  Daus,  Virchow's  Arch.  f.  path.  Anat.,  1907,  cxc,  196. 


S<jr.tMOL  S  CELLED   (:.lk(:l\()\LI  1S5 

Buscil-C(-Ut-d  Typf  ( Fi^.  124).  -Under  this  cMpiion,  Krompecher'  de- 
scribfd  :i  parricularl\'  lu-nijin  varic-rv  ot  laninoina  of  the  skin.  Ir 
contspoiuls  lo  tlu-  (.aneroids  oi  loiUnt  iikcis  ot  the  oldc  i  wnri-is.  I  he 
name  su^jiested  In  Kionipeclui  is  iiiitoi  tunate,  tor  nearl\  all  orlur 
epidernial  carcinomas  are  deiived  liom  rlu-  basal  cells,  \shile  it  is  ques- 
tionable it  ilu  \aiiir\'  to  which  lu-  a|")plucl  the  ttrm  really  is  derived 
from  (luse  cells.  ihesc-  tumors  are  characteii/ed  b\  small  deeply 
staining  cells  ot  \  arious  forms.  1  hey  are  usually  polyhedral,  but  may 
approach  the-  columnar  or  the  spindle  form,  and  are  notable  chieHy 
tor  the  lack  of  reseiidilance  to  tin-  ipulcrmal  cills.  In  some  instances, 
rhe\-  are  so  closely  related  to  the  glands  of  rh.e  skin  that  origin  from 
this  souici.'  has  been  sutiiiested. 

Fk;.  1^4 


Basal-celled  carcinoma  of  e\elid,  showing  normal  epidermis  and  carcmoma  columns 
which  bear  no  resemblance  to  normal  epithelium.  1  here  is  a  sparse  round-celled 
infiltration. 

Coenen-  particularly'  has  expressed  the  belief  that  they  develop  from 
either  the  sudoriferous  or  sebaceous  glands  and  involve  the  epidermis 
secondarih'.  In  some  specimens  the  glands  seem  unquestionably  to 
be  the  point  of  origin.  In  others,  again,  the  epidermis  seems  equally 
clearly  to  be  the  source  of  the  aberrant  cells.  Mallory  maintains  that 
thev  arise  from  the  hair  follicles.  In  some  specimens  cell  columns 
ma}-  be  traced  from  the  follicles.  It  would  seem,  therefore,  that  these 
tumors  have  several  sources  of  origin.     The  cell  columns  form  a  net- 

^  Der  Hasalzellenkrebs,  Fischer.  Jena,  1903. 
-  Berlin,  klin.  W'ochenschr.,  1907,  xliv,  662. 


186  CARCINOMA 

work  resembling  certain  endotheliomas.  It  has  been  suggested  that 
the  basal  cells  are  endothelial  in  character.  Like  the  endotheliomas, 
too,  they  show  little  disposition  to  the  formation  of  metastases,  but 
do  tend  to  recur  if  removal  is  not  thorough.  Not  uncommonly  multiple 
tumors  appear  slmultaneoush^  They  grow  slowly  about  the  periphery 
and  always  remain  superficial,  sometimes  even  healing  at  one  border 
and  extending  in  another  direction.  They  are  usuall}^  sharply  defined, 
the  connective  tissue  surrounding  them  being  little  infiltrated  by  round 
cells  and  retaining  its  normal  acidophilic  color  reaction.  They  are 
clinically  the  most  benign  of  the  infiltrating  epithelial  tumors. 

Fig.  125 


/ 

'       \'  ^ 

/ 

-e 

*'■% 

>-*-'*^ 

i^             '    i 

- 

0l^  ,  -•' 

■■■■■■   ,  -  ■;-frk"l 

Z' 

'fl» 

.c'^^ 

?    i  _ 

<h%^ 

" 

'                     4 

f 

4V^^ 

^      ^^«r 

s- 

-'    X 

->../. 

^^^    " 

y 

>  r           %^               ^ 

^                          /    »» 

--         ^ 

^ 

t*  r 

^ 

^' 

■  ^ '  ^'-'^^-i-^y-:: 

Carcinoma  of  the  tongue,  showing  nests  of  cells,  the  centre  of  which  can  be  identified 
as  of  epithelial  origin,  but  show  evidence  of  rapid  growth. 

The  Mucous  Membrane  Type. — The  epitheliomas  going  out  from  squa- 
mous cells  which  line  mucous  membrane  differ  from  those  developing 
from  epidermis  in  having  less  disposition  to  form  pearls,  since  they 
deviate  more  rapidly  from  the  mother  tj^pe  and  are  correspondingly 
more  malignant.  This  may  be  because  mucous  surfaces  are  more 
subject  to  maceration,  which  necessitates  a  more  frequent  replace- 
ment of  cells  and,  therefore,  more  active  proliferation.  In  addition  to 
this,  the  abutting  connective  tissue  is  less  dense  and  undergoes  reactive 
changes  more  quickly.  They  are  found  most  frequenth^  on  the  cervix, 
lips,  tongue  (Fig.  125),  and  gums,  less  often  in  the  esophagus,  pharynx, 
larynx,  vagina,  and  penis,  and  urinary  system.     Ulceration  is  common 


GLAXDUL.IR  CIRC  I  SO  M.I  ^<^7 

and  the  formation  of  fungiform  tumors  is  more  usual  than  with  skin 
carcinomas.  In  harmon\  with  the-  greater  clt\iation  of  these  cells 
tioni  the  iioiiiial  they  u;rovv  more  lapulK  aiul  form  early  metastases. 
I  hey  make  up  a  larj^e  proportion  of  the  surface  carcinomas.  I  heir 
location  in  regu)ns  where  irritation  is  fre(juent  has  ^i\en  prominence 
to  the  theory  of  irritation  in  etiolofiy. 

Glandular  Carcinoma.  This  t\  pe  is  developed  from  glands.  Formerly 
it  was  the  custom  to  include  the  more  highly  differentiated  tumors 
under  the  head  of  mahj^nant  adenomas,  which  was  a  suitahle  designa- 
tion, inasmuch  as  it  indicated  that  the  normal  gland  structure  was 
retained  and   that  the  sunounding  tissue  was  invaded.      1  he  term  de- 


FiG.  126 


^^^'M 


Glandular  carcinoma  of  mamma.     The  gland  lumina  are  retained  in  some  places 

and  filled  up  m  others. 

mands  that  the  tumor  be  formed  of  glands  normal  except  for  the  rate 
and  direction  of  growth.  The  glands  must  be  lined  by  a  single  layer 
of  epithelium,  but  so  rarely  are  the  glands  lined  by  a  single  layer  of 
epithelium  that  a  separate  classification  for  such  forms  has  been  largely- 
abandoned.  In  contradistinction  to  these  the  type  in  which  the  glandular 
lumen  is  filled  with  cells  was  designated  by  the  term  adenocarcinoma; 
and  when  all  trace  of  gland  structure  was  lost  the  t}pe  was  called 
carcinoma  without  a  qualifying  prefix.  But  since  all  these  varieties 
frequently  occur  in  a  single  tumor  they  are  at  present  grouped  together 
under   the  term   glandular  carcinoma'    (Fig.    126).      These   tumors   are 

>  Kaufmann,  \'ircho\v's  Arch.  f.  path.  .Anat.,  1898,  cliv,  i. 


188 


CARCINOMA 


found  most  frequently  in  the  gastro-intestinal  tract,  uterus,  mamma, 
and  prostate,  but  may  occur  in  any  glandular  organ,  but  rarely  in  the 
kidney  (Fig.  127)  and  liver. 

Fin.  127 


■■■-■■.iAMi<- 


Glandular  carcinoma  in  the  kidney,  secondary  nodule 
Fig.  128 

^  •  ■  .,..,;■.•.•"•■        ^^...y§^. 

Intestinal  mucosa  showing  earliest  stage  of  change  from  normal;  slight  elongation 
of  glands,  with  round-celled  infiltration. 


f,r^  . 


It  is  the  tumors  derived  from  glands  that  give  point  to  the  observa- 
tion of  Adami  that  in  malignancy  the  "habit  of  function  is  replaced 


GL.l.\Jjt  I..IR  (:.ll<i:/.\u.\Ll  ]s;r) 

b\'  the  habit  of  {growth.'*  I  his  ()l)sci  vnrion  is  tlie  ke\'  to  the  reccj^iii- 
tion  of  this  chiss  of  tumors.  Those  glands  wliose  functional  activity 
can  he  demonstrated  microscopically  show  their  first  deviation  from  the 


■'r 


Active  glandular  proliferation.     The  cells  lining  the  glands  have  proliferated, 
but  the  lumen  is  not  filled. 

normal  by  the  loss  of  their  activity  ^Fig.  128).  In  the  lesser  devia- 
tions such  a  displacement  of  function  by  growth  ma\'  be  only  partial, 
and  increased  growth  may  be  attended  by  a  partial  performance  of 
function   (Fig.    129J.     While  the  loss  of  function  of  a  cell  indicates  a 

Fig.  130 


^"^  -  '  1^    .  -0 .  ^^ 


The  gland  outline  has  been  lost  and  the  cell  columns  invade  the  surrounding  tissue, 
and  are  attended  b}'  formation  of  new  stroma. 

probable  malignancv,  the  proof  that  such  is  the  case  is  furnished  onl\' 
when  invasion  of  the  surrounding  tissue  can  be  detected  (Fig.  130). 
The  relation  of  the  cells  to  the  easil\-  demonstrated   basement  mem- 


190  CARCINOMA 

brane  supplies  a  convenient  criterion.  This  fact  is  important,  for  in 
many  of  the  polypoid  adenomas  function  may  be  entirely  abandoned 
for  growth  and  the  tumor  yet  be  benign.  As  the  tumor  progresses 
the  tendency  is  for  the  glands  to  become  filled  more  and  more  with 
epithelial  cells  until  the  lumen  has  entirely  disappeared  and  all  trace  of 
glandular  structure  is  lost. 

Those  glandular  carcinomas  which  occur  in  mucous  membranes 
usually  form  ulcers,  notably  in  the  intestinal  tract  and  uterus,  and 
assume  some  of  the  characteristics  of  tumors  derived  from  the  surface 
epithelium.  They  are  particularly  liable  to  secondary  degeneration, 
of  a  type  which  differs  according  to  the  organ  involved,  e.   g.,  colloid 

Fig.  131 


t*  » 


,-7-"^^ 


—      / 


r       •', 


0  •  f 


,  .*  -- 


" 

■q 

» i^^f 

&     J^ 

*.^   i 

^ 

*^ 

/  ^^ 

c*    s 

'    "       */"^ 

) 

^ 

■i^ 

^  -^ 

- 

1^ 

^ 

^ 

^' 

» 

v'*'^ 

"^ 

V^ 

J 

' 

/■ 

s,  ^    ^'^ 

'*  >-  ^r.f 

-^ 

'^ 

J 

Encephaloid  carcinoma.     Large  alveoli  with  relatively  small  amount  of  connective 

tissue. 

degeneration  in  cancer  of  the  stomach.  In  their  manner  of  growth 
they  do  not  differ  from  other  cancers  except  that  they  are  more  hkely 
to  give  rise  to  transplantation  metastases  (cancers  of  the  ovary)  and, 
perhaps,  less  hkely  than  squamous-celled  carcinoma,  to  give  rise  to 
bloodvessel  metastases.  The  contrary  is  true  of  glandular  carcinomas 
which  are  not  connected  with  the  surface.  In  these  metastasis  is  more 
apt  to  occur  than  in  the  squamous  variety.  Because  many  of  the 
glandular  organs  possess  a  natural  capsule  this  disposition  to  metas- 
tasis may  be  lessened  and  the  tendency  to  invade  the  surrounding 
tissue  is  strikingly  Hmited.  The  importance  of  this  capsule  becomes 
very  evident  when  tumors  of  the  gastro-intestinal  tract  are  compared 
with  those  of  the  thyroid. 


STRL  en  M./L   CL.lSS/I/C.mo.X  Of  C.lkCJXO.M.l 


1<)1 


Structural  Classification.  The  classification  of  carcinomas  accord- 
\n^  to  tin-  amoiiiu  ol  coniuctive  tissue  or  according  to  the  t\pe  of 
clefieneration    present,    is   ol    \aliu-   in 

ceiram    situations  in  tktt  innnin«;  the  !''<•■  '32 

protinosis.       Accorilmir    ro   this    I'l.issi-         /e^    ao^   ^-.'^^^ 
tit 
posei 


■)rot:nosis.      Accoiclinn   to  this   classi-       fj^f  6  ^  t-  Ai'^fS)' (!i  K: 2f ',' 

ication.    when    a    carcinoma    is  com-       '?'*    «^-^/v  «,  &*• '^•Ji'  «.^V;       ...     ,*> 

DOsed     of    hhrous     tissue    and     cells        ^  <\*^><^,S'^' 'i^^-^'^iJ' 4 ',>!>! k^/? 


they    ma}-    be  very    maHgnant    (tig.        '^y^<^^'i-^.0®MS^^^i:h-y-.^ 
132).     It  is    the   type  of  the   cell  and       Encephaloid    carcinoma,   showing  the 
not    the    number   that    indicates    the  very  small  amount  of  stroma, 

rate    of   growth.     If   the    connective 

tissue  is  in  excess  it  is  a  scirrhous  cancer.  The  cells  may  appear  as 
small  nests  (Fig.  133)  or  singl}'  or  in  narrow  columns  (Fig.  134)  in 
large  areas  of  connective  tissue.      Here  again   the   proportion  of  cells 


slow  growth;  but,  on  the  other  hand,      ^.^^'^^3>|''i';'*si^^<-C'^lC{'?.'^^^^ 


-^.- 
•-..  ^ 


Fig.  133 


tUt^' 


Scirrhus  of  breast,  with  well-dehned  cell  nests  in  certain  areas      Individual  cells  at  left. 


to   connective   tissue   ma\'   give    little  evidence   of  the  character  of  the 
tumor.     Those  in  which  the  cells  are  sparsest  may   give   rise  to   early 


192  CARCINOMA 

metastasis.  Any  of  the  elementan^  t3^pes  (squamous,  glandular,  etc.) 
may  form  any  structural  type  at  some  period  of  their  development, 
and,  therefore,  the  consideration  of  the  latter  confuses  rather  than 
clarifies  the  classification  of  carcinomas.  In  like  manner,  the  desig- 
nation according  to  the  type  of  degeneration,  as  colloid  carcinoma, 
while  it  suggests  the  most  common  source  of  the  tumor,  yet,  on  the 
whole,  emphasizes  too  much  the  importance  of  secondar}^  characters 
and  tends  to  confuse  rather  than  elucidate  the  real  nature  of  carcinomas. 

Fig.  134  . 


# 


•■    * 


Scirrhus  of  breast,  with  cells  in  single  columns. 

Diagnosis. — Clinical  Diagnosis. — After  the  detailed  consideration  of 
the  nature  and  pathogenesis  of  carcinoma  a  brief  consideration  of  their 
clinical   manifestations  will   be  useful   from   a   practical   point  of  view. 

Jge. — Age  is  a  contributory  datum  in  the  diagnosis  of  carcinoma, 
smce  the  large  majority  of  cases  occur  after  the  thirty-fifth  year.  While 
carcinoma  is  comparatively  rare  in  young  persons,  it  is  at  the  same  time 
the  most  frequent  epithelial  tumor;  hence  a  chronic  ulcer  in  a  young 
person,  if  a  specific  ulcerative  disease  can  be  excluded,  should  give  rise 
to  suspicion  of  carcinoma.  In  the  young  the  growth  of  these  tumors 
is  rapid,  the  age  of  the  patient  being,  in  fact,  more  useful  in  prognosis 
than  in  diagnosis,  for  the  local  signs  should  always  make  the  diagnosis 
possible. 


i)/.i(:.\(js/s  or  c.iRcisoM.i  I9:i 

Cachexia. — "1  his  is  alvva\s  a  late  sij;n  ot  carcinoma  and  si^niHcs  an 
extensive  in\asi<)n  or  tlie  existence  of  complications.  Much  mischief 
has  aiisin  lioni  consiihi  in<;  the  |-)resence  ot  cachexia  necessan'  tor 
diagnosis,  the  nature  ot  a  tumor,  especially  a  deep-seated  one,  being 
too  often  unrecognized  because  cachexia  is  not  present.  Cachexia 
is  distinctiveh'  a  terminal  manifestation,  and  is  more  properl\'  placed 
in  the  |iosrm()irem  protocol  than  in  rlu-  clinical  history. 

Pain.  Pain  in  cancer  is  due  to  the  invasion  of  sensitive  areas  by 
the  growth.  It  is  a  late  symptom  and  is  usuall\'  preceded  by  extensive 
infiltration.  It  is  usually  lancinating  and  intermittent  but  later  may 
become  constant,  in  which  case  other  factors  than  invading  cells  usuall\' 
pla\  a  part.  InHammatorx-  complications  or  pressure  on  other  organs 
ma\    produce  pain. 

Macroscopic  Appearance. — A  carcinoma  manifests  itself  as  a  tumor 
or  an  ulcer  or  both  combined.  If  an  ulcer  appears  primaril\'  it  indicates 
that  the  disease  originated  in  the  epithelium  ot  the  ulcerated  surface. 
In  some  cases  superficial  carcinomas  may  for  a  time  present  no  ulcera- 
tion, but  sooner  or  later  the  surface  breaks  down.  On  the  other  hand, 
a  neoplasm  which  originates  in  deeper  tissue  may  involve  the  surface 
secondarily.  Usually  ulceration  is  one  of  the  earliest  clinical  manifesta- 
tions of  carcinoma  of  the  epithelial  surface. 

Ulcerative  Type. — Since  carcinoma  is  an  infiltrating  growth,  ulcera- 
tion is  obviouslv  certain  w^hen  surface  epithelium  is  affected.  Con- 
verseh",  ever\'  chronic  ulcer  should  suggest  the  possibility  of  carcinoma. 
The  contour  of  an  infiltrative  fibro-epithelial  ulcerating  tumor  is,  in 
general,  circular,  though  it  does  not  possess  a  distinctive  outline.  1  he 
ulcer  which  it  produces  is  characterized  by  its  dense  border,  which 
is  one  of  the  chief  signs  of  carcinoma,  and  cannot  be  too  carefully- 
noticed.  The  border  is  usually  vertical,  but  may  be  sloping  or  under- 
mined. If  it  is  extensively  undermined  the  growth  is  probabl}'  of  deep 
origin  and  involves  the  surface  b}'  an  ulcerative  process  due  to  a  second- 
ary infection.  The  floor  of  the  ulcer  is  granular  and  friable  and  bleeds 
easily.  Frequently,  in  the  granulations,  whitish  areas,  the  "cancer 
plugs"  interspersed  b}'  pinkish  connective  tissue,  may  be  seen.  In  the 
border  of  the  ulcer  wherever  the  epithelial  nests  approach  the  surface 
theA'  ma\'  be  seen  as  small  whitish  points  or  "plugs,"  which  may  be 
pressed  out  like  comedones.  In  mucous  membranes,  likewise,  the  edges 
of  the  ulcer  are  dense,  though  less  so  than  when  surface  epithelium  is 
invaded,  and  the  "plugs"  may  not  be  so  readily  discernible. 

Tumorous  Type. — The  nodular  carcinomas  present  little  that  is  char- 
acteristic except  their  location.     Pitting  of  the  skin  over  them  is  often 
vet}-  noticeable,  and    the    increase  of    the  superficial    vessels   indicates 
somewhat  the  nature  of  the  tumor. 
13 


194  CARCINOMA 

These  points  taken  together  with  the  location  in  an  epithehal  tissue 
often  give  a  presumptive  diagnosis.  The  density  of  these  tumors  is 
the  characteristic  feature  and  even  when  deeply  seated,  is  at  once 
apparent  to  the  palpating  fingers.  There  is  usually  a  lack  of  mobility 
owing  to  the  infiltrative  character  of  the  tumor,  which  does  not  permit 
it  to  glide  about  within  the  capsule  as  in  true  encapsulation.  There 
may  be  a  pseudocapsule,  due  not  to  true  encapsulation  brought  about 
by  formation  of  new  fibrous  tissue,  but  to  the  central  growth  which 
pushes  aside  and  compresses  a  shell  of  the  surrounding  tissue. 

Microscopic  Diagnosis. — It  cannot  be  too  strongly  emphasized  that, 
no  matter  how  certain  the  clinical  or  macroscopic  diagnosis  of  carcinoma 
may  be,  a  careful  microscopic  examination  of  each  tumor  should  be 
made  since  only  in  this  way  can  the  clinician  keep  his  bedside  diag- 
nostic skill  on  a  high  plane  of  pathological  advancement.  The  variety 
of  carcinoma  often  can  be  determined  only  by  microscopic  examination, 
and  in  rare  instances  even  a  general  diagnosis  of  carcinoma  is  impos- 
sible without  this  procedure.  For  this  purpose  numerous  sections 
of  the  tumor  must  be  removed  from  such  regions  of  the  tumor  and 
treated  in  such  manner  that  the  following  points  can  be  determined 
With  the  greatest  facility. 

Invasion  of  Surrounding  Tissue. — The  only  certain  criterion  of  car- 
cinoma is  the  invasion  of  the  surrounding  tissue  by  the  tumor  cells. 
In  microscopic  examination,  the  border-line,  between  the  advancing 
epithelium  and  the  connective  tissue  surrounding  it,  must  be  constantly 
kept  in  mind.  This  border-line  may  be  sharply  defined  where  the 
basement  membrane  is  easily  determined,  as  in  the  intestine,  but  less 
easily  where  it  is  absent,  as  in  the  uterus.  In  the  absence  of  definite 
evidence  of  invasion  of  the  surrounding  tissue  a  positive  diagnosis  is 
not  permissible  notwithstanding  the  appearance  of  the  cells.  In  deter- 
mining this  point  certain  conditions  which  are  likely  to  cause  confusion 
must  be  kept  in  mind.  Among  them  are  displacements  resulting  from 
the  healing  of  wounds,  particularly  where  two  types  of  epithelium 
join,  as  in  the  cervix;  mechanical  displacement  of  tissue  in  the  prep- 
aration of  the  section;  and  reactive  inflammatory  processes  which 
may  cause  proliferation  simulating  an  extension  of  the  epithelium  into 
the  surrounding  tissue.  When  epithelial  cells  are  discovered  out  of 
their  normal  relations  where  such  possibilities  exist  other  evidence 
of  malignancy  must  be  considered.  Important  as  is  the  occurrence  of 
epithelium  beyond  its  normal  boundaries  for  recognition  of  the  mahg- 
nant  growth,  it  is  in  itself  not  conclusive.  When  epithelium  is  discovered 
without  its  normal  habitat,  if  there  is  no  change  in  cell  type  point- 
ing to  changed  biological  characters,  the  probability  is  that  it  has  gained 
this   position   by  means   other  than  its  own   autonomous   growth,   and 


MICROSCOPIC  DI.ICXOSIR  OF  C.I Rcl .\/j.\l .1  1<I5 

should  lu'  ;Ki,tpticl  ;is  m;i li<;ii;i ill  dmK  ;iltti  t;ii(liill\-  considcnn^  its 
bu)li)<i;ical  characters  as  well  as  its  histolo^^ual  a|)|)caiancc. 

(!lj(ini!^,<  ill  Crll  '/>'/>'•■.  I  hf  pro^rcssixc  change  in  ct-ll  t  \  pc  tiom 
thi-  noiiiial,  liill\  ditKiintiatc-d  t\  |h-  to  the  less  diflereiitiared,  usualU'  in 
some,  thouj^h  variable  degree,  parallels  the  invasion  of  the  surroundiiif^ 
tissue.  I  his  manifests  itself  m  the  lorni  of  the  cells,  and  if  the\'  have 
specific  characters,  r.  i^.,  prickle  cells  m  skin,  goblet  cells  in  digestive 
tract,  the\'  lose  them  and  aiijiroach  more  closel\'  the  undifferentiated 
embi\()nal  cell.  1  he  change  in  cell  typt-  is  always  present  in  some 
degree  in  carcinoma.  In  malignant  adenomas  and  other  more  highly 
developed  of  the  glandular  carcinomas  the  cell  type  is  very  slightly 
altered,  so  slightl\  ,  m  tact,  that  the  function  of  the  normal  cell  may 
be  imitated,  l^sually  in  these  tumors,  a  gradation  into  adenocarcinomas 
with  a  corresponding  change  in  cell  t^pe  ma\'  be  observed  m  other 
parts  of  the  tumor.  Invasion  of  surrounding  tissue  and  metastatic 
formation  ma}'  occur  with  little  or  no  change  in  cell  t\'pe.  Ihis  has 
been  called,  with  doubtful  propriety-,  metastasis  of  benign  tumors. 
It  is  observed  among  epithelial  organs  most  frequently'  in  the  thyroid. 
These  should  be  regarded  as  malignant  tumors  with  the  minimum  of 
cell  deviation.  Usually  the  degree  of  malignanc\'  is  indicated  by  the 
degree  of  alteration  m  the  cell  t^'pe;  the  greater  the  deviation  from 
the  normal  the  more  malignant  the  tumor. 

Atypical  Mitosis. — The  presence  of  involutional  cell  forms  heightens 
the  probabilit\'  of  malignant  growth  in  some  instances,  but  the}'  may 
be  very  numerous  in  tumors  of  low^  malignanc}'  or  even  in  reactne 
proliferations.  Atypical  mitosis  has  been  advanced,  particularly  by 
Hansemann'  as  a  valuable  diagnostic  sign  of  malignancy,  and  while 
not  of  universal  applicability  it  is  useful  in  man\'  instances.  The  mere 
presence  of  mitotic  figures  is  indicative  of  rapid  proliferation,  and  in 
itself  is  a  presumptive  sign  of  abnormal  growth;  but  it  is  the  irregular 
and  unequal  development  of  the  chromosomes  at  the  nuclear  poles 
that  IS  particularly  suggestive  of  malignancy.  Care  must  be  taken 
that  in  a  dividing  cell  which  has  passed  the  metaphase,  an  oblique 
section,  which  cuts  the  centre  of  one  aster  and  but  the  edge  of  another, 
is  not  interpreted  as  an  irregular  mitosis.  Hencke  believes  only  serial 
sections  can  obviate  such  an  error,  but  usualh  xhey  are  unnecessary  if 
the  sections  are  not  cut  too  thin.  The  unequal  division  of  the  chromo- 
somes IS  evidence  of  a  disturbed  proliferation,  but  as  a  diagnostic  sign 
of  carcinoma  its  value  is  lessened  hy  the  fact  that  it  is  b\'  no  means 
always  present  and  that  it  ma}'  be  present  in  reactive  processes.  It 
IS  of  value,   however,  in   the  presence  of  other  signs.     The  number  of 

'  Die  mikroskop;sch.  Diagnostik  bcisartige  Geschwiilste,  Hirscliwald,  Berlin,  1897. 


196  CARCINOMA 

mitotic   figures   is   sometimes   regarded   as   a   measure  of  the   degree   of 
malignancy,  but  it  is  an  unreliable  sign. 

Direction  of  the  Mitotic  Axis. — The  direction  of  the  axis  of  the  mitotic 
spindle  has  been  considered  by  Amann^  as  a  valuable  sign  in  diagnosis. 
This  axis  normally  is  parallel  to  the  basement  membrane,  so  that  the. 
cells  resulting  from  mitosis  lie  in  the  same  plane. ^  In  malignant  growths 
the  axis  of  division  deviates  from  the  parallel  and  consequently  the 
cells  become  piled  upon  each  other.  This  sign  is  mentioned  only  to 
warn  the  beginner  against  its  uncertaint}^  Mitosis  is  seen  but  seldom 
in  routine  examinations  in  tumors  of  this  character,  and  artefacts  are 
often  mistaken  for  it,  with  the  result  that  a  diagnosis  of  malignancy 
is  frequently  made  on  these  premises.  The  mere  piling  up  of  cells 
should  not  be  mistaken  for  malignancy,  since  it  may  be  simulated  by 
contraction  of  the  gland  in  a  longitudinal  direction.  It  is  never  more 
than  a  suspicious  sign  and  never,  in  the  absence  of  infiltrative  growth, 
is  it  alone  evidence  of  malignancy. 

Round-celled  Infiltration. — Ribbert  emphasized  the  importance  in  diag- 
nosis of  round-celled  infiltration  about  the  border  of  the  advancing 
carcinoma.  The  sign  is  of  great  value  in  many  instances,  but  I  am 
disposed  to  agree  with  Hencke  that  it  is  subject  to  too  many  errors  in 
interpretation  to  be  of  decisive  value.  Carcinomas,  especially  those 
of  the  glandular  type,  may  be  malignant  without  cellular  infiltration. 
On  the  other  hand,  round-celled  infiltration  may  be  found  associated 
with  other  conditions  than  carcinoma;  for  example,  chronic  ulcers, 
syphilis,  and  tuberculosis.  Chronic  ulcerative  processes  (especially 
of  the  cervix  and  stomach)  can  often  be  distinguished  from  carcinoma 
by  the  fact  that  in  the  former  the  infiltration  is  greater  in  the  older 
necrosing  area,  while  in  carcinoma  it  is  most  intense  about  the  advanc- 
ing border.  In  syphilitic  and  tuberculous  processes,  specific  signs  of 
these  diseases  must  be  found  before  they  can  be  distinguished  from 
carcinoma.  The  presence  of  round-celled  infiltration  is  most  valuable 
as  a  diagnostic  sign  of  carcinoma  where  other  causes  for  the  condition 
are  not  present,  especially  in  cases  of  parenchymatous  tumors. 

Relation  to  Elastic  Tissue. — Abel  advanced  the  belief  that  in  beginning 
epithelioma  the  cells  grew  around  and  enclosed  the  elastic  fibers,  while 
benign  proliferations  pushed  these  fibers  aside  and  did  not  enclose  them. 
Recent  investigations  tend  to  confirm  the  fact  that  epithelial  cells  have 
some  influence  on  the  production  of  elastic  tissue,  but  in  a  sense  diflTerent 
from  that  understood  by  Abel.  It  has  been  determined  that  elastic 
tissue   does  not  develop   about   epithelial  growths.     This   seems   to  be 

1  Mikroskopisch.  Gynakologischen  Diagnostik,  Bergmann,  Wiesbaden,  1897. 
^Abel,  Arch.  f.  Gynak.,  1901,  Ixiv,  316. 


TRi:.rr.\fi:\T  or  circisomi  I!»7 

clc;iil\  shown  iii  ;icl\  aiuitl  ^lourlis,  Inir  lor  tin-  diagnosis  of  earl\'  car- 
cinonui  it  has  hrtk-  value. 

M icrochc'tnical  Rt-cictiuii.  I  he-  niicrochciiiical  reactions  of  cells  in 
carcinoma  is  too  \ariahle  to  be  ot  f^reat  diagnostic  value.  Lsualh  in 
beginning  malignancy  the  cells  stain  more  deepl\'  with  many  nuclear 
d\es,  particularly  hematoxylin.  In  many  carcinomas  in  which  there 
is  a  disturbance  in  nutrition  the  nuclei  ma\'  be  large  and  pale.  \\  hen 
the  cells  undergo  degeneration  they  react  specifically  for  the  t\  pe  of 
degeneration  present. 

Treatment.      I  reatment  may  be  dnided  into  palliative  and  curative. 

Palliative.  It  is  to  Czerny's  credit  that  renewed  attention  has  been 
directed  to  the  fact  that  much  can  be  done  for  the  carcinoma  patient 
after  hope  of  cure  is  past.  I  he  treatment  of  incurable  cases  has  been 
too  often  relegated  to  the  quack.  For  this  the  practitioner  is  not  entireK' 
to  blame.  A  drowning  man  will  grasp  at  a  straw,  and  when  the  patient's 
disease  is  pronounced  incurable  by  his  physician,  he  too  often  hastens 
to  place  himself  in  the  hands  of  any  charlatan  who  will  promise  a  cure. 
It  becomes  the  problem  of  the  reputable  practitioner  to  counteract 
this  tendency.  No  one  should  care  to  retain  a  patient  by  holding  out 
false  hopes  even  to  save  him  from  falling  into  the  hands  of  the  charlatan. 
The  duty  of  the  practitioner  is  to  state  plainly  to  the  patient  or  to 
his  friends  that  the  disease  is  incurable,  but  at  the  same  time  he  can 
emphasize  the  fact  that  he  has  the  power  to  relieve  suffering  and  pro- 
long life.  In  his  personality  and  his  reputation  for  skill  and  probity 
on  the  one  hand,  and  in  the  intelligence  of  the  sufferer  on  the  other 
hand,  lies  the  possibility  of  retaining  these  patients. 

Medical  men  have  been  at  fault  in  two  directions.  Their  knowledge 
of  tumors  is  often  obviousl}'  limited,  as  the  patient  discovers  from  a 
faulty  diagnosis  or  prognosis,  and  too  often  the  patient  receives  the 
impression  that  a  fatal  prognosis  implies  a  total  lack  of  power  for  good, 
an  opinion  heightened  because  too  often  the  utmost  is  not  done  to 
relieve  his  suffering.  ihen,  too,  the  charlatan  plays  on  the  general 
ignorance  of  the  public  by  declaring  every  tumor  malignant,  and  thus 
treats  as  carcinomas  innocent  conditions  with  a  larger  percentage  of 
cures  than  the  skilled  surgeon  obtains  in  true  carcinoma.  In  the  recog- 
nition of  these  facts  lies  our  chief  power  to  prevent  these  patients  from 
falling  into  irresponsible  hands.  Man\'  practitioners  do  not  regard 
it  as  unfortunate  if  the  patient  overestimates  the  power  of  palliative 
treatment  to  limit  the  rate  of  growth  and  regards  such  treatment  with 
a  faith  not  warranted  by  experience.  In  retaining  the  patient  the 
physician  preserves  for  himself  an  opportunity  to  study  the  life  histor\' 
of  the  disease  which,  aside  from  perfecting  his  knowledge,  stimulates 
him  in  the  effort  to  recognize  the  disease  earlier  in  future  cases. 


198  CARCINOMA 

Palliative  treatment  includes  a  great  variety  of  measures,  varying 
from  the  exhibition  of  an  anodyne  to  the  boldest  operation.  When 
the  primary  tumor  can  be  removed  without  any  considerable  risk  to 
life  it  is  frequently  desirable  to  do  so.  With  glandular  involvement 
beyond  the  reach  of  the  operator,  death  is  certain;  but  with  the  chief 
tumor  removed  and  the  patient  freed  from  the  toxins  produced  by  it, 
the  renewed  hope  and  mental  tranquillity  often  give  the  patient  a  period 
of  comparative  health  and  courage  which  well  repay  for  the  incon- 
venience of  the  operation.  If  death  is  ultimately  produced  by  visceral 
metastasis  it  is  usually  attended  by  infinitely  less  suffering  than  the 
primary  tumor  would  have  caused. 

Frequently,  the  secondary  tumor,  perchance  in  lung  or  liver,  kills 
the  patient  without  his  being  long  aware  of  the  inevitable  end.  I  am 
firmly  of  the  opinion  that  much  suffering  can  frequently  be  saved  by 
judiciously  selected  radical  palliative  operations.  Unfortunately,  the 
problem  is  often  a  very  complicated  one  and  demands  the  highest  degree 
of  surgical  judgment.  Risk  of  operative  death  and  the  immediate 
suffering  from  the  operation  must  be  taken  into  account  in  determin- 
ing the  right  path  to  pursue.  These  factors  depend  upon  conditions 
that  cannot  be  treated  in  an  abstract  way  because  the  skill  of  the 
surgeon,  the  facilities  for  good  work  and  the  estimation  of  the  power  of 
the  patient  to  withstand  the  operation  must  all  be  considered  in  each 
individual  case.  The  efficiency  of  the  surgeon  depends  largely  upon 
his  ability  to  estimate  these  factors  correctly.  The  patient  is  often 
asked  to  decide  for  himself,  but  obviously  the  surgeon  is  in  possession 
of  facts  which  will  enable  him  alone  to  form  an  accurate  judgment, 
in  which  judgment  the  patient  need  not  in  every  instance  be  asked 
to  participate.  It  certainly  is  within  the  province  of  the  surgeon  to 
decide  what  is  best  for  those  who  place  themselves  in  his  hands,  and 
he  should  not  hesitate  to  assume  a  proper  share  of  responsibility.  He 
has,  indeed,  to  answer  to  the  science  he  represents  for  his  acts,  and  must 
exercise  care  to  avoid  bringing  discredit  upon  it. 

A  palliative  operation  may  be  counted  as  a  failure  among  the  friends 
of  the  patient  and  the  value  of  operations  for  the  cure  of  malignant 
disease  in  general  be  discredited.  This  misunderstanding  may  be 
avoided  somewhat  by  explaining  to  them  the  risk  and  the  reason  for 
assuming  the  risk  and  making  it  clear  that  a  permanent  cure  is  not 
expected.  How  much  the  notion  that,  even  if  the  operation  result 
fatall)^,  the  patient  will  be  saved  much  suffering,  has  to  do  with  deciding 
in  favor  of  the  operation  must  be  estimated  in  each  case.  This  phase 
often  appeals  to  the  none  too  sympathetic  friends;  but  even  though  the 
patient  is  in  accord  with  this  view,  and  even  though  the  surgeon  may 


TRE.ITMEXr  OI    C.IKCISOM.I  I!l!» 

lean  toward  a   Nur/scluan   j^hilosoplu  ,  In-  has  no  n^hr  in  an\'  case  t<j 
act  as  txccutiomi . 

I  lu-  iiii(\  ot  tin  |ii  actitionci  luic  as  ilscw  luii-  is  to  piolcjn^  lite  as 
lonti  as  possible.  At  rlu-  same  time-  tradition  at  runes  outweij^hs  science 
aiul  pie\eius  the  patient  tioni  recei\in^  all  the  benefits  science  has  to 
ortVi.  W  Inn  the  lait\-  understand  the  facts  as  we  do,  each  failure  will 
hut  einphasi/i-  the  need  tor  eailiei  opiiation  in  similar  cases,  and  uill 
not  deter  those  who  would  otherwise  seek.  surj;ical  reliet.  I'ailure  to 
save  a  patient  with  appendicitis  in  most  communities  but  increases 
the  N'i^ilance  to  seek  eaiU  operation  m  other  cases,  and  the  lait\'  will 
assume  the  same  attitude  toward  carcinoma  failures  when  they  have 
gained  a  like  faith  in  the  correctness  of  the  surgical  diagnosis  and 
treatment  of  malignant  disease. 

\\  hen  complete  removal  cannot  be  accomplished,  partial  removal  b\- 
the  cauter\'  or  curette  or  b}^  escharotic  chemicals  is  to  be  considered. 
Whenever  there  is  a  necrotic  surface  or  a  tendency  to  hemorrhage  one 
or  more  of  these  ma}'  be  employed  with  benefit.  Usually  the  curette, 
followed  by  the  Paquelin  or  actual  cautery,  to  check  hemorrhage  and 
to  close  the  absorbing  surface,  is  the  most  useful.  The  temporary  im- 
provement following  such  procedure  is  often  quite  gratifying.  This  is 
particularly  true  of  carcinoma  of  the  cervix.  These  measures  may  be 
repeated  from  time  to  time  as  the  indication  arises.  \\  hen  the  curette 
or  cauter\'  cannot  be  used,  escharotics  may  be  employed.  Calcium 
carbide  has  been  highly  recommended,  and  nitric  acid  or  the  more 
recenth'  advocated  acetone  ma\'  be  employed.  In  the  use  of  any 
escharotic  care  should  be  exercised  to  avoid  large  vessels,  as  an  alarm- 
ing hemorrhage  may  result  when  the  dead  tissue  separates.  The  use 
of  the  cautery  may  often  precede  a  radical  palliative  operation.  The 
disposal  of  the  sloughing  surface  lessens  the  danger  of  postoperative 
sepsis  and  the  contraction  of  the  scar  resulting  from  the  cauterization 
may  bring  the  borders  of  the  tumor  more  rapidh'  within  the  reach  ot 
the  operator.  By  relieving  the  infective  processes  and  the  associated 
inflammatory  reaction  about  the  border  of  the  tumor  the  rate  of  growth 
ma\'  be  lessened. 

Deodorants  and  disinfectants  are  often  of  great  comfort  to  the  sufterer. 
Potassium  permanganate  in  strong  solution  answers  both  ot  these  indica- 
tions. It  ma\-  be  used  either  as  a  lotion  or  in  wet  packs,  as  ma\-  be 
required. 

The  various  electrical  rays  have  been  employed  as  palliative  measures. 
In  some  cases  the  rate  of  growth  is  lessened,  but  rarel\'  does  regres- 
sion follow.  Pain  is  frequentl\-  controlled  for  a  long  time.  In  other 
instances,  no  results  are  obtained,  and  growth  may  even  be  stimulated. 
The  .v-ra3-s   may  be  employed   as  a   matter  of  experiment  in  all  cases 


200  CARCINOMA 

where  there  is  any  hope  of  deriving  benefit.  Radium  may  be  employed 
in  the  same  way  as  the  x-rays. 

When  the  preceding  methods  are  not  indicated,  palHation  may  be 
secured  by  means  of  drugs  and  chemicals  either  by  exhibition  by  mouth 
or  hypodermically,  or  by  local  use.  The  anodynes  all  have  their  legiti- 
mate field.  The  coal-tar  derivatives  and  the  usual  somnifacients  may 
relieve  the  pain  in  the  early  cases  where  the  suffering  is  not  too  great. 
Hyoscine  hydrobromate  may  serve  a  similar  purpose.  Sooner  or  later 
morphine  must  be  resorted  to,  and  enough  should  be  given  to  make 
the  patient's  condition  tolerable.  The  probable  duration  of  the  disease 
must  be  taken  into  account,  but  when  the  probable  lease  of  life  can  be 
expressed  in  weeks  the  relief  which  morphine  alone  can  give  must 
not  be  denied.  In  slowly  growing  tumors  the  use  of  morphine  should 
be  postponed  as  long  as  possible  and  the  local  and  operative  treatment 
should  have  preference. 

Local  treatment  may  consist  either  of  injection  into  the  tumor  or 
applications  to  its  surface,  with  or  without  a  partial  removal  by  the 
curette  or  similar  means. 

For  the  relief  of  pain  local  injections  are  frequently  beneficial.  Several 
cubic  centimeters  of  50  per  cent,  to  70  per  cent,  alcohol  may  be  injected, 
repeated  every  few  days.  This  treatment,  introduced  by  Czerny, 
gives  much  relief  in  some  instances  and  by  the  formation  of  fibrous- 
tissue  limits  the  rate  of  growth.  I  have  found  that  the  addition  of 
I  per  cent,  hydrochloric  acid  materially  increases  the  power  of  alcohol 
to  relieve  pain.  These  injections,  aside  from  the  possible  good  they 
may  do,  tend  much  to  lighten  the  gloom  that  naturally  surrounds  the 
patient. 

Injections  of  various  antitoxins  have  had  little  or  no  effect  either 
palliative  or  curative,  and  none  of  them  deserves  any  confidence.  Tryp- 
sin seems,  in  some  instances,  to  produce  a  temporary  regression,  but 
its  use  has  been  tainted  by  methods  that  smack  of  quacketA^  and  a 
just  estimate  cannot  be  placed  upon  it  at  this  time. 

Methylene  blue^  by  mouth  has  been  used  as  a  palliative,  and  some 
practitioners  seem  to  repose  faith  in  its  use.  It  is  obviousl}^  difficult 
to  estimate  the  degree  of  inhibition  which  the  drug  may  exercise  upon 
the  rate  of  growth. 

Curative. — Sera. — Antitoxins,  vaccines,  and  ferments  are  in  the 
experimental  stage  and  have  no  place  here,  promising  as  is  this  field 
in  therapeutics. 

Chemical  Agents. — Certain  chemicals,  e.  g.,  arsenic  and  strong 
acids,  may  cause  enough  local  destruction  of  tissue  to  bring  about  a 

^  Jacobi,  Jour.  Amer.  Med.  Assoc,  1909,  xlvii,  1545. 


TKE.ITMEM  <)l'  CARCISOMA  201 

cure  in  a  ver\'  limited  tumor  about  the  face,  but  they  are  so  much 
inferior  to  other  measures  that  they  are  never  justified. 

I'hvskai.  Achnts.  I  he  v-rays  and  radium  are  curative  tor  the 
basal-celled  carcinomas  about  riu-  face,  nose,  and  evelids,  though  a 
few  skilled  operators  have  claimed  a  wider  Held.  1  he  ettect  m  general 
on  tumors  outside  of  this  region  is  not  pronounced,  and  is  in  every  wa\' 
inferior  to  operative  removal.  It  is  the  failure  of  Rontgenologists  to 
limit  their  efforts  to  this  known  field  of  effectiveness  that  has  caused 
surgeons  to  be  skeptical  of  the  value  of  the  .v-ra\s  in  any  form  of 
carcinoma. 

Fulguration,  inrroduct-d  by  de  Keating-Hart,  appears  to  be  useful  in 
certain  conditions.  Czerny  expressed  great  hope  in  this  method.  1  he 
use  and  limitations  of  this  method  appears  to  parallel  that  ot  the  .v-rays. 

Operative. —  In  principle  the  treatment  of  carcinoma  consists  in 
the  removal  of  all  the  diseased  tissue  and  no  more.  Were  we  able  to 
identify  all  the  malignant  tissue,  this  principle  would  be  as  easily  carried 
out  as  in  the  benign  encapsulated  tumors.  Since  this  is  not  possible 
it  is  necessar\'  to  depend  upon  a  knowledge  of  the  habit  of  growth  of 
a  tumor  and  remove  not  only  the  tumor  but  also  that  tissue  in  which 
dissemination  is  most  likely  to  have  occurred.  This  requires  a  knowl- 
edge of  the  character  of  the  tumor,  its  stage  of  development,  and  the 
topographic  anatom\"  of  the  region  occupied  by  the  tumor.  These 
various  factors  may  be  reviewed  under  a  number  of  subheads. 

Kind  of  Tumor. — In  a  few  carcinomas  local  excision  is  sufficient. 
This  applies  to  the  basal-celled  variety  of  the  face.  The  disastrous 
results  of  a  failure  to  individualize  in  the  selection  of  treatment  is 
exemplified  in  cancers  of  the  lips.  When  these  are  treated  by  the 
simple  means  applicable  to  the  basal-celled  type,  recurrence  results. 
In  tumors  of  this  class  the  removal  of  the  glands  most  likely  to  be 
affected  is  required.  The  results  obtained  by  fitting  the  operation  to 
the  disease  is  well  illustrated  by  the  excellent  results  obtained  by  Hal- 
sted  in  carcinoma  of  the  breast.  Others  of  equal  ambition  but  less 
training  seek  to  emulate  these  achievements  b\'  removing  as  much 
tissue  as  possible  in  all  instances.  As  statistics  show,  the  majorit}'  of 
operations,  though  done  with  the  idea  of  cure,  are,  in  fact,  but  pallia- 
tive operations.  Surgeons  should  seek  to  perfect  their  knowledge,  so 
that  a  more  accurate  prognosis  before  operation  can  be  formulated.  If 
this  were  possible,  the  beginning  carcinoma  would  more  often  receive 
the  extensive  operation  and  the  extensive  one  the  slighter  operation, 
making  it  what  it  proves  to  be,  notwithstanding  its  extent,  a  palliative 
operation. 

Topographical  Anatomy. — The  channels  of  dissemination  being  known, 
the   foci   of  likeh'   metastasis   should   be   removed.     The   rule   may   be 


202  CARCINOMA 

applied  that  if  there  are  no  evidences  of  metastasis  the  next  proximal 
group  of  glands  should  be  removed.  There  comes  a  time  in  every  case 
when,  no  further  removal  is  possible.  In  carcinoma  of  the  breast  we 
may  remove  the  axillary  glands,  and  if  these  be  involved  the  supra- 
clavicular glands  must  be  removed.  In  carcinoma  of  the  stomach  it 
is  only  the  glands  lying  near  the  stomach  that  can  be  removed.  The 
justification  for  the  removal  of  innocent  tissue  in  order  to  remove  that 
likely  to  be  affected  differs  in  the  various  regions.  Muscles  of  the  chest 
and  neck  are  removed  in  order  to  facilitate  the  removal  of  the  channels 
of  transportation. 

The  State  of  the  Patient. — Upon  the  evidence  outlined  above  the 
operation  must  be  planned.  This  having  been  done,  it  is  necessary 
to  consider  how  extensive  an  operation,  if  any,  the  patient  is  able  to 
withstand.  A  patient  with  advanced  organic  disease  is  a  poor  subject 
for  a  grave  operation.  The  patient's  condition  may  be  good,  but  the 
demands  of  the  operation  may  be  excessive.  It  may  be  necessary  to 
perform  the  operation  in  two  stages,  as  in  tumors  of  the  gut,  particu- 
larly where  obstruction  has  taken  place.  The  surroundings  under 
which  the  patient  must  be  operated  and  the  skill  of  the  surgeon  are 
important  factors. 

General  Points  in  Technique. — The  tumor  should  be  handled  as  little 
as  possible.  It  is  beHeved  that  handling  the  tumor  roughly  may  tend 
to  promote  metastasis.  In  order  to  avoid  this,  the  excision  should  be 
begun  at  the  proximal  portion  of  the  field  of  operation.  This  closes 
off  the  avenues  of  dissemination. 

Courage  to  Perform  the  Needed  Operation. — The  type  of  operation 
required  having  been  determined,  the  surgeon  should  insist  upon  its 
performance,  being  swayed  by  neither  the  wishes  of  the  patient  nor  his 
own  timidity.  Partial  operations  are  often  done  because  of  a  desire  to 
avoid  inconveniencing  the  patient  or  to  avoid  mutilating  operations. 
The  folly  of  this  is  most  often  exemplified  in  carcinoma  of  the  lip. 
Often  incomplete  operations  are  done  because,  as  the  operation  pro- 
gresses, the  surgeon  realizes  that  the  technical  requirements  exceed  his 
skill.  This  is  most  often  demonstrated  in  carcinoma  of  the  abdomen.  It 
is  too  little  appreciated  that  the  surgery  of  carcinoma  is  in  the  highest 
sense  major  surgery,  and  the  operator  who  enters  this  field  should  be 
master  of  surgical  technique.  With  less  than  this,  either  the  resistance  of 
the  patient  will  be  unduly  taxed  or  a  partial  operation  will  be  per- 
formed. Fully  equipped,  the  surgeon  will  often  enough  find  his  poise 
and  courage  put  to  the  severest  test. 


C  II  A  I'   r  K  k     X  \    I 

General  Conception.  A  cyst  is  a  collcctuMi  ol  tliiul  within  a  incni- 
hiaiu'.  Man\-  of  thcni  are  not  true  tumors,  though  riuii  walls  develop 
as  111]  111  lit!  to  acconiiiioclatc  tiu'  contints;  sonu-  ot  tlu-m  an-  accidental 
complications  oF  true  tuniois;  and  sonic  arc  dcNciopcd  m  the  course 
ot  the  glow  th  oi  true  tumors. 

Simple  Retention  Cysts.  This  type  may  result  from  some  disturb- 
ance in  function  or  development  of  a  gland;  a  normal  secretion  ma\- 
be  retained,  an  excessive  secretion  ma\'  be  produced,  or  some  fetal 
structure  may  fail  to  disappear.  They  are  most  conveniently  con- 
sidered under  these  heads. 

Occlusion  Cysts. — The  closure  of  the  outlet  duct  of  a  secreting  gland 
frequently'  results  in  a  cyst.  The  wall  is  formed  by  the  gland  walls, 
which  are  frequently  modified  by  the  pressure  of  the  contained  Huid, 
the  epithelium  usually  becoming  flatter;  or  the  cyst  wall  may  pro- 
liferate so  as  to  accommodate  the  increasing  cystic  contents.  Familiar 
examples  are  ranulas,  ovula  Nabothi,  wens,  galactoceles,  and  perhaps, 
follicle  C3'sts  of  the  ovary. 

Secretory  Cysts. — These  ma}'  result  from  abnormal  or  excessive  secre- 
tion in  glands  which  have  no  outlet  duct.  The  most  familiar  examples 
are  found  in  the  thyroid  and  pituitary  glands.  The  cyst  wall  may  be 
formed  from  the  sinus  wall  or  from  the  capsule  of  the  gland  when  the 
C3'sts  are  large.  Usually  in  this  type  there  is  a  qualitative  variation 
in  the  secretion  which  prevents  absorption,  though  it  is  stated  that  a 
(juantitative  change  also  tends  to  cyst  production.  The  lining  cells 
are  usually-  flattened  from  pressure,  but  otherwise  show  little  change. 

Vestigial  Cysts. — These  seem  to  be  due  to  the  failure  of  some  fetal 
structure  to  become  obliterated.  The  most  familiar  types  are  the 
branchiogenic  and  thyroglossal  cysts,  and  encysted  hydrocele.  When 
the  outlet  ducts  of  such  structures  remain  open,  fistulas  are  formed. 
The  lining  cells  are  modified  cells  of  the  organ  the}'  represent.  Rarer 
examples  are  c\'sts  of  the  urachus,  the  Wolflfian  duct,  the  Miillerian 
duct,  the  organ  of  Rosenmiiller,  the  h\datids  of  Morgagni.  and  the 
vitello-intestmal  duct. 

Developmental  Cysts. — This  type  is  due  to  arrested  glandular  develop- 
ment and  is  represented  by  the  congenital  cystic  kidne\'.     The  condi- 


204  CY^STS 

tion  is  brought  about  by  the  failure  of  the  developing  tubules  to  coalesce 
properly. 

Regression  Cysts. — Cysts  of  this  type  result  from  normal  regressive 
processes,  as  seen  in  the  luteal  cysts  of  the  ovary. 

Proliferative  Cysts.  —  In  contradistinction  to  the  foregoing  group, 
proliferative  cysts  show  a  development  of  the  epithelium  in  excess  of 
that  required  to  envelop  the  fluid.  In  this  they  show  a  disposition  to 
excess  of  cell  proliferation  over  cell  secretion.  Many  of  these  cysts  are 
benign  in  their  growth;  others,  while  essentially  benign,  may  become 
malignant  under  certain  conditions;  others  early  and  regularly  show 
malignant  tendencies.  It  will  be  convenient  to  consider  them  under 
corresponding  subheads. 

Benign  Cysts. — It  is  frequently  difficult  to  separate  this  group  from 
the  simple  retention  cysts.  They  may  occur  in  an}^  of  the  parenchyma- 
tous organs,  but  most  frequentl}^  in  the  ovary.  The}^  develop  from  the 
germinal  epithelium,  the  parovarium,  or  the  ''rests"  of  Pfliiger's  columns. 
Their  classification  under  this  head  is  justified  by  the  proliferation  of 
the  epithelial  cells  of  the  cyst  wall  compared  with  the  passive  state 
of  the  epithelium  of  the  simple  retention  cysts.  In  the  proliferative 
type  there  frequently  occur  papillary  outgrowths  into  the  mterior. 
They  are  usually  accompanied  by  a  small  amount  of  connective  tissue 
and  a  few  bloodvessels,  but  long  columns  of  independent  cells  ma}^  be 
found.  According  to  Borst,  this  phenomena  is  unmistakable  evidence 
of  initial  activity  in  the  cyst  wall.  This  type  of  cyst  may  be  lined  by 
a  variety  of  cells,  but  usually  by  a  single  layer  of  cuboid  or  columnar 
cells.  The  walls  desquamate  and  their  cells  may  be  found  in  various 
degrees  of  degeneration  in  the  cyst  contents.  Usually  these  floating 
cells  imbibe  fluid  and  become  large  and  round  and  often  markedly 
acidophilic.  The  cystic  contents  vary  greatly.  Frequently  it  is  clear 
serous  fluid,  sometimes  pseudomucinous,  and  more  rarely  hemorrhagic. 

Semimalignant  Cysts. — No  sharp  dividing  line  exists  between  this 
and  the  preceding  group,  but  the  clinical  importance  of  the  type  is 
sufl&cient  to  warrant  its  being  emphasized  by  a  separate  classification. 
Any  proHferative  cyst,  particularly  if  characterized  by  papillar}^  forma- 
tion, may  become  malignant.  The  papillary  prolongations  growing 
inward  may  after  a  time  come  in  contact  with  the  opposite  wall  and 
by  eroding  it  pass  outside  the  organ  in  which  they  originated.  If  in 
the  ovary,  as  is  usually  the  case,  these  papillary  prolongations  may 
become  implanted  upon  the  surrounding  peritoneum  and  there  con- 
tinue their  growth.  B}^  the  rupture  of  these  cysts  from  traumatism 
or  from  attempts  at  removal,  particles  of  the  tumor  may  escape  and 
form  secondary  growths,  which  usually  show  a  more  malignant  tendency 


COSC.I-.MT.II.  CYSTS  20;') 

flKin    rhc   oiiiiinal    rumoi".       I  lu-se   cysts   show    rluir   nialifinanr    disposi- 
iioii  Litf  aiul  iiiuliT  what  nia\    he  called  acculcntal  coiulirioiis. 

Mdlii^iKiiit  dysls.  I  Ills  i\|)(  ol  c\sr  shows  a  disposition  to  inhltrate 
tin-  hasi-  In  tin-  h)iniati()n  ol  cell  ^i()ii|is  in  the  wall  ol  the  c\st.  I  he 
serous  cysts  ot  the  ovary  are  the  chut  icpiesciitatives  ot  this  f^roup. 
1  hese  were  called  h\'  \\alde\er  glandular,  and  In  Ptannenstiei  evertinji 
cysts.  Many  ol  the-  carcuionias  of  the  o\ary  hi«;ni  ni  this  manner,  and 
usiiall\  It  IS  not  easy  to  determine  whether  they  should  be  regarded 
priniaiil)  as  carcinomas  with  a  slight  disposition  to  c\st  formation, 
like  man\-  ot  the  adenocarcinomas,  or  as  cysts,  with  vei  \  malignant 
teiulencKs.  He  this  as  it  ma\',  the  surrounding  tissue  is  soon  in\aded 
without  the  rupture  of  the  cyst,  as  in  the  preceding  group.  Malignant 
c\"sts  never  attain  large  size,  because  the  cells,  being  of  a  lower  order, 
tend  to  multiply  instead  of  forming  a  distending  secretion.  The  same 
disposition  ot  cyst  walls  is  observed  in  other  situations,  notabl\'  in 
the  mamma. 

Degeneration  Cysts.  In  the  course  of  growth  of  many  tumors 
c\'stic  cavities  develop,  usually  as  the  result  of  some  nutritive  dis- 
turbance. This  may  be  a  degenerative  process  which  goes  on  to  lique- 
faction or,  more  frequently-,  may  result  from  a  hemorrhage,  after  which 
the  material  in  the  affected  area  undergoes  certain  autolytic  changes. 
The  contents  of  such  cAsts  var\'  greatly.  In  the  tirst  type  the  contents 
may  be  semit^uid,  as  from  myxoid  or  fatty  degeneration.  In  the  hemor- 
rhagic type  the  contents  may  be  red  from  the  hemoglobin,  or  straw- 
colored  when  the  hemoglobin  has  been  absorbed  or  precipitated;  in 
either  e\'ent,  cholesterin  cr\'stals  remain  to  indicate  the  mode  of  origin. 
The  cyst  wall  in  both  types  ma\'  be  made  up  of  ragged,  parti}'  degen- 
erated, tumor  tissue  undergoing  liquefaction.  When  hemorrhage  has 
been  the  cause  of  the  cyst,  the  w^all  ma}'  be  more  or  less  fibrous  from 
the  compression  of  the  fibrous  elements  of  the  tumor,  or  the  presence 
of  the  blood  may  excite  the  fibrous  tissue  of  the  tumor  to  the  forma- 
tion of  a  more  or  less  perfect  capsule.  When  hemorrhage  complicates 
the  degenerative  t\'pe,  as  is  frequently  the  case,  the  structure  of  the 
cyst  wall  depends  upon  w^hich  type  of  degeneration  was  the  predomi- 
nating element  in  its  production. 

Congenital  Cysts. — Cysts  of  this  type  result  from  some  fault  of 
development.  Thev  represent  structures  at  no  time  normal  to  the 
body,  differing  in  this  respect  and  in  their  greater  complexity  from 
cysts  which  develop  from  vestigial  remains,  and  include  a  broad  variety. 
Usuall\'  they  are  dependent  on  the  failure  of  some  fold  to  be  obliterated, 
and  may  occur  on  the  surface  of  the  body  or  may  be  included  within 
the  bod\'  cavity.  The  contents  depend  on  the  nature  of  the  tissue 
included.      In    the   simple   skin   dermoids   the   contents    resemble   cuta- 


206  CYSTS 

neous  products,  sebaceous  material,  epithelial  detritus,  etc.  In  other 
regions,  where  the  inclusions  are  more  complicated,  other  epidermal 
products  are  added.  This  is  particularly  noteworthy  in  dermoids  of 
the  ovary,  where  teeth  and  hair  are  commonly  found  embedded  in  the 
sebaceous  material.  In  the  class  of  developmental  anomalies,  failure 
of  cranial  fissures  to  close  gives  rise  to  hernias  which  appear  in  the 
form  of  cystic  tumors.  They  usually  represent  the  covering  of  the 
neural  canal  or  the  meninges  alone,  and  contain  the  normal  fluid  of 
the  central  nervous  system. 

Other  developmental  disturbances  may  result  in  cystic  cavities. 
The  lymph  cysts  of  the  neck,  which  are  enormously  dilated  lymph 
spaces,  usually  unconnected  with  lymph  vessels,  present  good  examples. 
Often  cavities  similar  in  character  but  connected  with  lymph  vessels, 
are  encountered  which  belong  properly  to  the  cavernous  lymphangio- 
matous  formations,  and  have  been  described  with  them. 

Diagnosis. — Macroscopic. — The  recognition  of  a  cyst  usually  depends 
upon  the  discovery  of  a  collection  of  fluid  in  an  abnormal  situation, 
or  in  abnormal  amount.  They  may  be  identified  by  the  globular  form, 
elasticity,  fluctuation  on  palpation,  and  by  the  removal  of  some  of  the 
contents  by  aspiration.  The  details  of  diagnosis  diff^er  according  to 
the  situation  and  will  be  given  in  the  regional  consideration  of  tumors. 

Microscopic. — The  nature  of  the  cyst  is  determined  in  part  by  its 
situation  and  life  history,  but  chiefly  from  the  microscopic  structure 
of  its  walls.  When  the  epithelial  cells  are  flatter  and  less  distinct  than 
normal  it  is  probably  a  retention  cyst.  The  evidence  of  epithelial  pro- 
liferation places  it  in  the  class  of  proliferative  cysts.  In  these  the  degree 
of  proliferative  activity  stands  in  a  direct  relation  to  their  clinical  char- 
acter. The  degeneration  cysts  are  devoid  of  epithelial  lining,  having 
instead  a  ragged  wall  of  the  tissue  of  the  tumor. 

Treatment. — The  benign  cysts  require  removal  when  from  their  size 
and  situation  they  cause  inconvenience.  The  semimalignant  should 
always  be  removed  when  discovered.  Local  removal  is  usually  suffi- 
cient. Malignant  proliferative  cysts  should  be  accorded  the  treatment 
applicable  to  malignant  tumors  in  general.  Degeneration  cysts  should 
be  treated  according  to  the  rules  governing  the  management  of  the 
tumors  in  which   the  c\^sts  form. 


C  W    \  V  T  I".  R     X  \'  I   I 
EMBinOll)    lUMORS 

Cc^NGKNi'i  Ai,  anoiiialu's  nia\'  ran^t-  in  degree  from  hirthmarks  to  normal 
plural  birth.  Man\'  of  them  play  a  part  as  the  point  of  origin  of  tumors; 
others  may  themselves  be  tumors;  many  are  of  no  interest  in  oncology, 
smce  the\'  neither  resemble  tumors  nor  give  rise  to  them.  Those  of 
the  first  two  groups  may  be  arbitrarily  divided  into  classes,  purel}'  as  a 
matter  of  cluneal  convenience  without  a  pretence  at  scientific  accuracw 

Classification. — Certain  groups  of  tumors  have  come,  under  the 
indefinite  term  of  "mixed  tumors,"  to  have  an  important  place  in  tumor 
pathologw  The}-  occup}^  the  salivary  glands,  the  mammary  glands, 
and  the  testicles  and  ovaries.  In  the  ovaries  and  testicles  congenital 
tumors  form,  composed  of  two  or  more  embryonal  lasers  with  cvsts. 
These  are  the  dermoid  cysts.  In  the  same  situation  other  tumors  are 
found  which  contain  products  from  all  three  of  the  embryonal  la\ers. 
1  hese  may  be  called  the  emhryomas.  Each  member  of  these  groups 
has  a  special  significance  according  to  the  region  in  which  it  occurs, 
and  a  more  detailed  account  of  essential  characteristics  will  be  given 
in  connection  with  the  various  regions. 

Mixed  Tumors. — These  tumors  are  found  particularly  in  the  salivary 
glands,  breasts,  and  testicles  (Fig.  135).  They  are  not  present  at 
birth,  usually  grow  slowh'  for  prolonged  periods,  and  then  take  on  rapid 
growth,  and,  breaking  through  their  capsules,  spread  into  the  sur- 
rounding tissue  and  manifest  other  evidence  of  malignancy.  Their  com- 
position varies  in  the  different  regions.  Cartilage  and  mA'xoid  tissue, 
together  with  epithelial  or  epithelioid  cells,  are  commonly  present. 
In  the  breast  cartilage  is  ordinarily  absent.  The  epithelioid  cells  are 
usualh'  arranged  in  strands  and  columns  identical  with  or  simulating 
endotheliomas.  Man}'  pathologists  disregard  the  other  elements,  and 
class  them  as  endotheliomas.  The  presence  of  cartilage  in  them  is 
accounted  for  as  the  result  of  metaplasia.  In  other  organs,  as  in  the 
testicle,  myxoid  and  glandular  elements  predominate  and  cartilage 
is  the  exception.  These  tumors  vary  much  in  detail,  but  their  general 
plan  IS  uniform  and  the  recognition  of  them  as  forming  a  common 
group  has  done  much  to  clarify  many  obscure  problems. 

Dermoids. — Dermoids  are  tumors  of  the  testicles  and  more  particularly 
of  the  ovaries,  composed  of  tissue  representing  two  or  more  layers  of 


208  EMBRYO  ID  TUMORS 

the   embn^o,    together  with   C3^stic   formation    (Fig.    136).     They   may 
contain  hair  and  the  products  of  the  sebaceous  glands,  and,  more  rarely, 

Fig.  135 


m^^^nm 


''^^^f^^ 


^        .^   .   ?   .  ^^ 


Mixed  tumor  of  submaxillary  gland. 

teeth.     The  Hning  of  the  cysts,  as  their  structure  indicates,  is  epider- 
moid.    Muscle   and  occasionally  neural   tissue  are  found.     The  tumor 

Fig.  136 


>¥ 


VCV.,,^ 


^ 


1     ! 

i;   ^,: 

'■    \  ' ■''^■:y,-  -.v.  • 

1 

Dermoid  cyst. 

-jl- 


may  undergo  gradual  growth,  but  this  is  usually  due  to  an  increase 
of  the  cystic  contents.  Rarely  are  they  the  starting  point  for  malig- 
nant growth. 


KMIikYoM.IS  209 

Embryomas.  I  iimois  torinccl  from  ;ill  tlntf  c  iiil)i  \  oiial  hiytis  with- 
out c\  srir  toiin.iiion  ait-  iioi  ml  ncjiuni  l\  ot  oiu'olo^ical  iiUcicsr.  I  hey 
ail-  toiiiul  most  I  H(Hiiiii  l\  m  flu-  ictiioii  ot  ilic  kiihu\',  in  the  region 
ot  the  saciiim  aiul  m  thr  hiam  and  |diai\n\.  I  he-  emhryonal  hiyc-rs 
are  i  ipiisiiiteil  m  \  aiiahle  proportions.  I  hese  tumors  iKJt  intre(juentl\' 
takt  on  lapiil  growth,  tormin^  tumois  lesenihlm^  the  sarc(imas  in 
structure. 

Etiology.  The  e.xact  origin  of  the  emhiyoul  tumors  has  not  heen 
dt  hmtil\  istahhshed,  hut  the  followinii  e.xjihinations,  out  ot  the  man\' 
which  ha\c-  hiin  atUanced,  mac  he  mentioned: 

1.  Mu  two  or  three  pohir  hodies  which  appear  during  the  matura- 
tion ot  tlie  ovum  are  beheved  to  become  impregnated  and  give  rise  to 
the  embryomas.  In  favor  of  tliis  view  is  the  fact  that  the  location  of 
some  of  the  embryomas,  notably  epignathous  and  sacral  tumors,  corre- 
sponds to  the  most  fiequent  location  of  the  polar  cells.  Against  this 
has  been  advanced  the  fact  that  as  many  as  five  embryomas  have  been 
observed  in  the  human  subject,  and  such  a  large  number  of  polar  bodies 
is  unknown. 

2.  Wilms  has  advanced  the  theory  that  these  tumors  are  derived 
from  the  blastomeres  of  the  developing  ovum,  which  are  supposed  to 
become  displaced  at  a  very  early  stage  of  development.  As  these  cells 
are  separated  at  a  time  when  differentiation  has  not  yet  taken  place, 
it  ma\'  be  assumed  that  wherever  they  develop  they  ma}',  following 
their  mherent  developmental  power,  produce  tissues  contaming  prod- 
ucts of  all  three  germinal  layers.  This  theor\-  admits  of  the  most 
universal  application,   and  is  now  generall}'  accepted. 

Diagnosis. — The  teratoid  tumors  are  recognized  b)'  the  presence  of 
cells  representing  two  or  more  germ  layers  and  by  their  location  in 
certain  regions.  The  constancy-  of  their  location  and  their  habit  ot 
growth  are  often  required  to  permit  the  identification  of  these  tumors, 
after  they  have  taken  on  rapid  growth.  The  failure  to  grasp  the  inter- 
relations of  the  various  types  and  stages  accounts  for  the  contusion  ot 
views  which  prevailed  until  the  ver}'  recent  past. 

Treatment. — 1  he  removal  of  the  tumor  when  in  the  inactive  stage 
IS  usually  a  simple  procedure.  After  the\'  have  escaped  their  capsule 
removal  requires  the  extensive  operations  of  any  other  malignant 
tumor. 


u 


CHAPTER    XVIII 
GRANULOMAS 

General  Conception. — Under  this  head  are  collected  a  number  of 
conditions  which  have,  in  common  with  true  tumors,  a  structure  dis- 
tinctly cellular  in  character.  The  term  itself  suggests  its  double  char- 
acter, a  tumorous  enlargement  and  a  structural  resemblance  to  the 
newly  formed  tissue  of  wound  healing.  It  is  desirable  to  discuss  granu- 
lomas in  conjunction  with  true  tumors,  as  their  origin,  situation,  and 
form  frequently  make  them  objects  of  interest  in  differential  diagnosis. 

The  fundamental  difference  between  the  granulomas  and  the  true 
tumors  is  that  the  former  are  purposive,  the  purpose  being  to  combat 
bacterial  invaders  and  to  repair  tissue.  Differentiation  depends  upon 
observing  the  changes  in  the  cells  which  tend  to  effect  this  dual  purpose. 
On  the  one  hand,  we  must  expect  to  find  the  leukocytic  and  phagocytic 
activities  of  acute  infections;  and  on  the  other  hand,  the  fibrin  forma- 
tion and  the  polyblastic  and  fibroblastic  activities  which  end  in  the 
production  of  new  tissue.  The  presence  of  these  activities  implies  that 
there  is  an  enemy  to  combat,  and  usually  we  can  identif}'^  the  offend- 
ing organism;  but  sometimes  it  cannot  be  found.  We  are  still  obliged 
to  class  such  cases  with  the  granulomas  purely  on  the  analogy  of  the 
tissue  activities. 

The  simplest  granulation  process  is  observed  in  the  healing  of  wounds, 
particularly  when  delayed  b}^  disturbed  nutrition  or  infection.  The 
pus-producing  organisms  are  usually  responsible  for  the  production  of 
luxuriant  granulations  (proud  flesh),  but  other  bacteria,  and  even 
chemical  and  mechanical  irritation  may  be  the  cause.  The  initial 
process  is  usually  inflammation,  in  which  there  is  a  heterogeneous 
mixture  of  mononuclear  and  polynuclear  leukocytes  with  large  cells, 
probably  identical  with  the  polyblasts  of  Maximow.  It  is  this  char- 
acteristic variety  of  cells  that  differentiates  young  inflammatory  tissue 
from  neoplasms. 

In  addition  to  the  cells  are  newly  formed  vessels  which  are  at  first 
mere  clefts  in  the  immature  fibrous  tissue,  but  soon  they  develop  fibrous 
walls.  The  character  of  the  vessel  walls  depends  upon  the  age  of  the 
process.  Certainly,  if  the  process  has  lasted  long  enough  to  warrant 
a  question  of  neoplasm,  the  vessel  walls  will  be  sufficiently  developed 
to    furnish    a    very  definite  diagnostic   point.      About    the   vessels   are 


SY  I'll  I  LIS  211 

numerous  hands  or  granules  of  Hbnn  vvliich  may  check  the  development 
ot  the  f^ranulatne  process  at  an  eari\'  immature  state.  In  such  cases 
the  mononuclear  cills  iuconu-  iiromnunr,  the-  polv  nuckars  are  sparse, 
and  tile  pol\hlasts  tew  or  ahsent.  The  vessel  walls  are  conHned  to  a 
smj^le  layer  of  cells  and  are  surrounded  b\'  Hbrin  hands.  In  such  con- 
ditions the  resemhiance  to  sarcoma  is  very  great,  and  to  arrive  at  a 
diagnosis  the  specific  cause  of  the  granulation  process  (tubercle  bacilli, 
spirochetes)  must  he  sought  and  the  life  histor\-  of  the  growth  be  taken 
into  account  when  the  specific  causative  agent  is  unknown  or  cannot 
be  identified. 

The  variation  in  the  structure  of  the  granulomas,  despite  a  general 
common  plan,  is  so  great  that  it  is  desirable  to  present  each  type  sepa- 
rately, since  the  histological  structure  in  itself  frequently  presents 
sufficient  exidence  on  w  Inch  to  base  a  diagnosis,  and  also  indicates  the 
specific  organism  involved.  They  may  be  considered  in  the  order  of 
their  frequenc\-  of  occurrence  as  diagnostic  problems. 

Syphilis. — There  is  no  disease  so  often  confused  with  neoplasms  as 
is  syphilis.  Tumors  are  no  exception  to  the  oft-quoted  dictum  that 
syphilis  may  simulate  any  disease.  The  syphilitic  lesions  likely  to  be 
mistaken  for  tumors  are  the  gummas  and  the  ulcerations  resulting 
from  them. 

Fig.  137 


"W?P«3 


."V   . 


Gumma  of  liver:  a,  spindle  cells  within  degenerated  area;  b,  small  round  cells. 

Microscopic  Appearance. — The  gummas  are  the  syphilitic  lesions  which 
may  be  included  with  the  granulomas  (Fig.  137).  The}"  are  formed 
primarily-  by  the  invasion  of  a  region,  usuall}-  about  a  vessel,  by  small 


212  GRANULOMAS 

spherical   cells   with    a    small   amount   of  protoplasm   and    a    relatively 
large  nucleus. 

The  area  invaded  extends,  and  when  the  gumma  is  fully  formed 
three  distinct  zones  can  be  discerned.  In  the  centre  is  a  necrotic  area 
composed  of  granular  debris  containing  nuclei  which  retain  their  stain- 
ing properties.  Surrounding  this  area  are  spindle  cells  arranged  in  a 
manner  more  or  less  tangential  to  the  circumference.  These  cells  are 
formed  from  the  granuloma  cells  above  mentioned,  which  follow  in  a 
general  way  the  development  of  the  granulation  tissue  cells  into  fibrous 
connective  tissue  in  wound  healing.  Surrounding  this  layer,  the  tissue 
is  infiltrated  with  unchanged  granuloma  cells.  This  region  is  not  sharply 
circumscribed,  but  shades  gradually  into  the  tissue  external  to  it. 

Fig.  138 


'^■^^'^ 


;^  >>'°',.^''--^'     '^-C  "'-i''''    "»''''-^'    J""'    '   ..-X"' /'" ■-°' 

■■,"''■•' '-\^'"  •'"''' :,i^^'.-     ''•  v"J-,     -    ^■.-J-.*^»\*i■■'C**-'^• 

^  -         /      '  .■»»'V*  ■       '';    ^~~»-      -'  ,    '•  .■  •■'.'.-  *-  •      ».  «   "  '.  .'■ 

Syphilitic  periostitis,  perivascular  infiltration. 

Giant  cells  may  be  found  in  any  of  these  regions.  Their  nuclei  are 
usually  diffusely  scattered  through  the  cytoplasm,  but  are  sometimes 
arranged  about  the  centre.  In  the  peripheral  layer,  bloodvessels  are 
usually  to  be  found  showing  the  typical  changes  of  syphilis.  The  endo- 
thehum  of  the  intima  shows  extensive  proliferation.  To  such  an  extent 
may  this  proliferation  extend  that  the  lumen  of  the  vessel  may  be  nearly 
or  quite  occluded.  The  media  may  likewise  be  the  seat  of  extensive 
hyperplasia.  The  adventitia  is  often  infiltrated  with  granuloma  cells. 
The  centre  of  gumma  is  prone  to  liquefaction,  which  follows  fatty 
degeneration. 

Macroscopic  Appearance. — The  submucous  or  subcutaneous  gummas  are 
nodules  varying  in  size  from  a  pea  to  a  walnut.  They  are  indefinitely 
circumscribed,  are  unattached  to  the  skin,  and  are  of  firm  consistency. 
As  they  extend  they  liquefy,  the  skin  is  no  longer  freely  movable  upon 
them  and  becomes  deep  red  or  bluish  red.  It  then  breaks  down  and 
an  ulcer  results.  The  ulcer  bears,  in  general,  the  form  of  the  gumma. 
Because  the  area  of  liquefaction  is  spherical,  the  ulcer  has  overhanging 
edges,  and  since  the  centre  alone  becomes  softened,  the  border  of  the 


Tl  HI.RIA  I.OSIS  '1\:\ 

iilcfi"  IS  liiin.  As  till-  uK(  I  .i(l\  ;iiuts  ilu-  process  ol  mlili  lation  ;in(l  li(|ii(- 
facrion  <.()iitiiuiis.  Ilu-  llooi  ol  ilu-  nicer  is  c<)\i-ir(i  \Mth  ;i  \(ll<)\sish 
(.Ichiis,  tin    iisiilr  ot  \\\v  li(|iut;Kt ion  ol  tin-  casi-^in-d  Cfiuif. 

\\  lull  tlusc  iiUiis  lual  sjioni  ancoiislv  or  as  a  ic-sult  ol  t  iiat  iiu-nt , 
rlu-  \i'llo\\  dihiis  (lisappcais  and  <:,i  annia  t  ion  tissnc  nplains  it.  I  lie 
oNii  hantini!:,  i-d<;cs  ap|"»i()ach  the  luw  ii,ranniai  ions  and  hc^in  to  c(ncr 
rluiii  with  a  dilu-arc  la\(i  ol  tpitlulinm.  Sometimes  the  processes  of 
hrahnLi,  and  hlc•akln^  down  ait-  (.■oinhnuil,  so  that  <;\  ions  hmiics  are 
pioducitl. 

I  he-  ixsnltiiiL;;  scars  arc  iisualK'  rcmarkahic  lor  rluii  dchcacw  I  hc\' 
all'  pearly  white,  ami  oitcn  jircscnr  a  radiatin^i;  arran<i:cnu-nr.  I  he 
borders,  m  marked  contrast,  are  brownish  red.  These  Hne  cicatrices 
may  be  combined  with  the  ulcerative  process. 

Observation  of  the  salient  features  thus  outlined  -the  necrotic 
centre  witli  the  preser\-ed  nuclei,  the  Ia\"er  of  cells  arran(j;ed  parallel 
to  tbe  circumference,  and  the  vascular  changes — will  lead  with  great 
accuracy  to  the  diagnosis  of  S3'philis,  and  refutes  the  statement  that 
there  is  nothing  characteristic  in  the  histology  of  the  gumma.  With 
these  microscopic  findings,  and  the  clinical  signs,  the  diagnosis  of  the 
lesion  from  true  tumors  is  generally  not  difficult.  Nevertheless,  there 
are  still  a  few  instances  in  which  the  therapeutic  test  may  be  used  with 
advantage.  This  is  particularly'  true  when  clinical  evidence  alone  is 
available.  When  both  clinical  and  microscopic  evidence  can  be  obtained 
a  therapeutic  test  should  rarely  be  necessary. 

When  It  is  deemed  necessaii'  to  emplo\'  the  therapeutic  test,  thirty 
to  sixty  grains  of  potassium  iodide  should  be  given  dail\'  for  three  or 
four  weeks.  Mercurial  ointment  should  be  used  on  the  ulcers.  If 
the  lesion  is  syphilitic,  the  dirt}-  yellow  base  of  the  ulcer  speedily  gives 
way  to  health)'  granulations,  the  overhanging  border  of  the  epidermis 
soon  blends  with  the  granulation  tissue,  and  the  advancing  epithelium 
is  outlined  b\'  a  bluish  margin.  These  signs  may  appear  in  a  few  days. 
If  the}'  do  not  appear  in  three  or  four  weeks,  the  test  may  be  considered 
negative  and  abandoned.  Very  rarely  will  heavier  doses  of  the  drug 
be  necessar\'. 

Demonstration  of  the  Spirochete  pallida  and  the  \\  assermann  reac- 
tion have  now  largely  displaced  the  therapeutic  test  in  diagnosis.  Both 
tests  are  more  positive,  but  require  special  facilities.  The  organism  can 
be  readil}'  demonstrated  in  acute  lesions,  but  the  service  of  a  laboratory 
expert  IS  required  for  the  performance  of  the  serum  test. 

Tuberculosis. — The  unit  of  tuberculosis  is  the  tubercle,  which  is  a 
reactive  process  on  the  part  of  the  tissue  against  the  invasion  of  the 
tubercle  bacillus.  Since  the  demonstration  of  the  latter  is  the  only 
positive  proof  of  tuberculosis,  it  might  be  expected  to  be  the  one  object 


214  GRANULOMAS 

of  diagnostic  endeavor,  as  it  is  in  the  examination  of  sputum  in  sus- 
pected cases  of  pulmonary  tuberculosis;  but  in  lesions  which  most  closely 
simulate  neoplasms  it  may  be  difficult  or  impossible  to  identify  the 
organism,  or  the  technique  of  identification  may  be  so  time-consuming 
as  to  make  it  impracticable  for  clinical  purposes.  In  such  cases  a  detailed 
study  of  the  pathological  anatomy  is  imperative  and  permits  a  positive 
diagnosis  in  the  majority  of  cases.  At  the  same  time  suspected  tissue 
should  not  be  promiscuously  cast  into  fixing  solutions,  but  portions 
should  be  reserved  for  animal  innoculation  in  order  that  definite  demon- 
stration may  be  added  to  the  conclusions  of  anatomical  examination. 
Macroscopic  Appearance. — When  the  primary  lesions  are  small  and 
before  caseation  has  taken  place,  they  are  grayish  white  and  translu- 
cent. After  caseation  has  taken  place  the  translucency  is  lost  and  they 
become  yellowish-white  nodules,  the  size  of  a  millet  seed  and  slightly 
elevated,  when  they  occur  on  the  surface  of  an  organ.  With  coalescence 
of  these  units  lesions  of  varying  size  may  result.  When  caseation  has 
not  taken  place  a  granular  moist  surface  is  presented  characteristic 
of  cellular  structures  in  general  and  in  no  way  indicating  the  tubercu- 
lous nature  of  the  lesion.  It  is  only  when  the  degeneration  has  taken 
place  and  the  dull  grayish  dry  "cheesy"  surface  appears  that  it  gives 
evidence  of  its  tuberculous  nature.  Positive  as  the  lesions  are  for  the 
identification  of  tuberculosis,  they  generally  occur  in  internal  organs, 
hence  are  rarely  available.  It  is  usually  the  fact  that  the  appearance 
of  the  tissue  is  negative,  together  with  the  history  and  physical  char- 
acters that  are  of  importance  in  clinical  examination. 

Fig.  139 


'"'':r.  •$.:■:}: 


Vi^*--.-'"'    '''.■•■■  ■'.■■ 


■.^\  \ 


'  :•'  -J-- 


Tubercle  in  lupus  of  ala  of  nose. 

Microscopic  Appearance  (Fig.  139). — Giant  cells  having  degenerated 
centres  and  many  ovoid  nuclei  arranged  about  the  periphery  are  the 
most  striking  sign  in  the  microscopic  diagnosis  of  tuberculosis.     The 


TLHERCiUJSIS  215 

presence  of  round  cells  and  epithelioid  cells  form  a  necessar\'  setting 
for  the  coniplction  of  the  picture.  The  ^iant  cells  are  usually-  arranged 
ahour  the  periphery  of  the  caseated  areas.  In  the  absence  of  j^iant 
cells  rlu-  presence  of  a  caseated  centre  with  epithelioid  cells  radiating 
toward  the  border  is  very  characteristic  I  v.  Baum^arten).  Kven  in 
the  absence  of  a  necrotic  area  the  presence  of  round  cells  surrounded 
b\-  epithelioid  cells,  resembling  closel\'  the  appearance  of  lymphoid 
nodules,  is  very  suggestive  of  tuberculosis.  These  may  exist  in  numbers 
without  the  giant  cells  and  the  caseating  centre.  The  tubercle  bacilli 
are  found  in  greater  abundance  in  the  giant  cells  and  the  caseated 
areas,  but  lesions  not  attended  b\-  giant-celled  formation  and  caseation 
also  permit  the  demonstration  of  the  bacilli.  Caseation  may  be  absent 
and  the  general  arrangement  of  round  cells  and  epithelioid  cells  must 
be  accepted  as  of  a  certain  diagnostic  value,  the  degree  of  certainty 
depending  on  the  region  from  which  the  tissue  was  obtained. 

The  giant  cells  of  syphilis  ma\-  also  have  their  nuclei  arranged 
peripherally  The  same  is  true  of  sarcoma  and  foreign  body  giant  cells. 
In  regions  where  hemorrhage  has  occurred  giant  cells  closeh'  resembling 
the  giant  cells  of  tuberculosis  are  often  formed  about  cholesterin  cr\'stals. 
Error  may  be  avoided  by  remembering  the  setting  in  which  the  true 
tubercle  giant  cell  is  formed.  In  case  of  doubt  the  demonstration  of 
the  bacilli  within  a  questionable  lesion  is  necessary  to  establish  the 
diagnosis.  In  certain  lesions  the  predominant  feature  is  a  sluggish 
granulation  such  as  is  seen  in  tuberculous  joint  disease,  and  the  demon- 
stration of  bacilli  is  very  difficult.  In  such  instances  it  ma\'  become 
necessary  to  resort  to  animal  inoculation.  A  bit  of  the  questionable 
tissue  is  rubbed  up  in  sterile  water  and  injected  into  the  peritoneal 
cavit)'  of  a  rabbit  or,  preferably,  a  guinea-pig.  If  the  lesion  be  tuber- 
culous the  animal  usually  responds  by  the  production  of  miliar}'  tubercles, 
which  are  fatal  in  from  four  to  ten  weeks.  Negative  results  may  be 
obtained  and  the  disease  still  be  tuberculosis,  for  the  animal  may  resist 
the  bacteria  or  the  tissue  inoculated  may  have  been  ordinary  granula- 
tion tissue,  superimposed  upon  the  tuberculous  tissue. 

More  recenth'  other  means  have  been  employed  for  the  diagnosis  of 
obscure  tuberculous  lesions.  The  oldest  of  these  is  the  employment 
of  tuberculin.  Small  doses  of  this  are  injected  into  the  suspect  and 
the  presence  of  tuberculosis  is  made  manifest  by  a  rise  in  temperature. 
Of  some  value  and  much  more  convenient  are  the  Moro  and  von  Pirquet^ 
tests.  These  are  not  to  be  given  any  specific  value  in  diagnosis  when 
the  question  is  between  tuberculosis  and  malignant  neoplasm. 

^  For  literature  see  WolfF-Eisner,  The  Ophthalmic  and  Cutaneous  Diagnosis  of 
Tuberculosis,  William   Wood   &:   Co.,   New  York,   1908. 


216  GRANULOMAS 

The  diagnosis  so  far  has  had  to  do  with  distinguishing  between  tuber- 
culosis and  those  tumors  which  have  granulation  tissue  as  their  pro- 
totype, namely,  sarcoma  and  other  granulomas,  particularly  syphilis. 
Frequently,  in  response  to  the  stimulus  of  tuberculous  granulation 
tissue,  epithelium  acquires  rapid  growth.  This  is  likely  to  occur  when 
the  tuberculous  process  invades  surfaces  bearing  epithelium.  When 
such  is  the  case  the  epithelium  begins  to  proliferate  and  comes  to  re- 
semble an  epithelial  tumor.  Such  growth  of  epithelium  does  not  lose 
its  relation  to  the  surface  epithelium,  and  if  this  is  remembered,  it  is 
not  likely  to  be  mistaken  for  neoplasm.  It  must  be  remembered  that 
not  infrequently  epithelial  tumors  are  established  on  the  basis  of  a 
preexisting  tuberculosis.  So  protean  is  tuberculosis  that  this  disease 
should  be  kept  in  mind  in  connection  with  a  vast  number  of  tumors, 
particularly  those  involving  lymph  glands,  skin,  and  mucous  surfaces. 

Rare  Forms  of  Granulomas. — There  remains  a  number  of  conditions 
properly  classed  as  granulomas  which  occasionally  present  problems 
in  tumor  diagnosis.  These  include  actinomycosis,  glanders,  leprosy, 
and  rhinoscleroma. 

Fig.  140 

•«. ^  r^9  ^  ^ ,3.  9^- 


i& 


%® 


;*-■#--  Of 


1^?" 

£;8  " 

J 

^ 

«, 

■^:^^n 

t^  if* 

\^ 

\^V/  ^     / 

ii 


Actinomycosis:  a,  granule  showing  radiating  filaments;  b,  granulation  tissue. 

Actinomycosis. — The  cause  of  this  disease  is  the  Streptothrix  actino- 
mycosis. The  lesions  are  granular  masses  which  usually  occur  m  the 
interior  of  the  body.  When  accessible  the  small  yellowish  granules 
visible  to  the  naked  eye  are  diagnostic.  Microscopic  examination 
reveals    the    characteristic    radiating    fungi    (Fig.    140).      Surrounding 


liOTKYOMYCOSIS 


217 


these  bodies  is  granulation  tissue.  In  very  chronic  cases  the  granula- 
tion tissue  ma\'  he  so  excessive  that  the  parasites  are  found  with  ditti- 
cult\  . 

Glanders.  In  t  xceediiigly  rare  instances  glanders  ma\'  cause  a 
granulating  rumor  which  might  he  mistaken  for  sarcoma.  Ihe  recover\- 
of  the  bacillus,  preferably  b\  guinea-pig  inoculation,  is  the  onl\'  certain 
means  of  diagnosis.  I  he  rapidity  of  the  progress  of  the  disease  is  usualh 
sufficient  to  distinguish  it  from  tumors. 

Leprosy.  liu-  clinical  course  is  distinctive  from  that  of  a  neoplasm. 
Occasionally,  local  tumorous  masses  ma\'  be  encountered. 

Rhinoscleroma.  Ihe  masses,  usually  irregularly  nodular,  which  this 
disease  produces  on  the  nose,  trachea,  or  lar\nx,  may  closely  resemble 
neoplasms.  When  the  nose  is  involved  the  disease  mav  imitate  rhino- 
ph\ma;  when  the  lar\nx  and  trachea  are  affected,  it  ma\'  suggest 
sarcoma.  I  he  bacilli,  when  found,  are  distinctive  and  the  presence  of 
large  granulation  cells  is  said  to  be  suggestive. 


Fig.  141 


a  - 


-!?u's."^  c^iv 


~S;.  -.cV^^S^-  =--.*'  -^SSS?-.. 


C 


S^SaW.- 


Botryomycosis:  a,  group  of  cocci;  b,  epithelium;  c,  bloodvessel. 

Botryomycosis.'  —  These  tumors  spring  usually  from  the  fingers  or 
other  exposed  surfaces  of  the  body  as  the  result  of  some  irritation. 
The\'  are  usually  not  larger  than  a  hazelnut.  Their  base  is  generally 
constricted,  often  to  a  pedicle.  They  do  not  differ  from  other  granulo- 
mas in  structure,  and  the  presence  of  groups  of  cocci  closely  resembling 
Staphylococcus  albus  is  said  to  be  distinctive  'Fig.  141  ). 


^  See  Gahinet,  Les  tumeurs  botryomycosiques,  Michalon.  Paris,  1902;   Sutton,  Amer. 
Jour.  Med.  Sci.,  191 1,  cxlii,  69. 


218  GRANULOMAS 

Mycosis  Fungoides^  (Fig.  142). — Under  this  head  AHbert  described  a 
disease  which  probably  belongs  with  the  granulomas,  though  a  specific 
cause  has  not  been  discovered.  It  is  characterized  by  the  formation 
of  nodules  beneath  the  skin,  which  may  either  regress  or  ulcerate.     The 

Fig.  142 

«'*  0  &   *©•    '•#     #»# 


^    ®  i?o  *-  *®  »•  ®  <^*  ^» '  !vO«    „  >  < 


,>^eVs>:f^  ft^*' -V^  '^-'^ 


Mycosis  fungoides. 

lymph  glands  are  sometimes  involved,  particularly  late  in  the  disease. 
The  structure  resembles  the  granulomas  in  a  general  way,  there  being 
a  reticulum  within  which  the  cells  lie.  The  cells  are  round,  ovoid, 
spindle  form,  or  branched. ^ 

^  For  a  complete  discussion  see  Hazen,  Jour.  Cutan.  Dis.,  191 1,  xxix,  521. 
^  Tilden,  Boston  Med.  and  Surg.  Jour.,  1885,  cxiii,  386;  Unna,  Die  Histopathologie 
der  Hautkrankheiten,  Hirschwald,  Berlin,  1894. 


F  A  \l   V     111 
REGIONAL  CONSIDERATION   OF    TUMORS 

CHAP  '1'  E  1^     X  I  X 

BIOLOGY    OF    TUMORS    AND    GP:NERAL    CLINICAL 
CONSIDERATIONS 

General  Diagnosis. — In  the  foregoing  chapters  the  biology  of  tumors 
in  geneniL  as  well  as.  their  individual  characteristics,  were  considered. 
It  is  a  combination  of  these  factors  that  make  it  possible  to  judge  the 
kind  and  character  of  an\'  particular  tumor.  The  application  of  this 
knowledge  demands  the  same  rules  as  govern  any  chnical  stud\-;  but 
special  considerations  must  be  employed  here,  because  of  the  difference 
which  exists  between  the  nature  of  tumors  and  the  nature  of  other 
processes  which  are  reactive  in  character.  This  fact  warrants  a  summar\' 
of  the  facts  ahead}'  presented. 

The  general  biology  of  tumors  presents  many  facts  common  to  all 
species  of  tumors,  since  they  are  all  proliferative  in  character.  It  also 
presents  many  points  of  difference  in  that  they  have  different  capacities 
for  growth,  dissemination,  and  degeneration.  It  is  the  comparison  of 
these  likes  and  differences  that  make  it  possible  to  identify-  the  species, 
that  is,  to  make  a  diagnosis. 

In  making  a  diagnosis  in  a  tumor  problem,  one  has  the  triple  question 
to  solve,  "Is  it  a  tumor?"  if  so,  "What  kind  of  a  tumor  r"  and  "Is  it  a 
primary  or  a  secondary  tumor?"  The  first  is  often  the  most  important 
clinically.  The  second  is  sometimes  onh"  a  matter  of  scientific  interest, 
but  usually  it  is  the  answer  to  this  question  that  determines  the  treat- 
ment. The  answer  to  the  second  carries  with  it,  as  a  rule,  the  answer 
to  the  third,  but  sometimes  a  secondary  tumor  is  regarded  as  primary, 
which  may  lead  to  error  in  treatment. 

The  question  as  to  whether  a  given  lesion  is  a  true  tumor  or  not  may 
open  up  the  widest  problems  in  general  diagnosis  and  ma}-  require 
the  most  diverse  means  of  differential  diagnosis.  For  instance,  a  mass 
within  the  abdomen  may  be  due  to  scybala,  inflammatory  exudate, 
or  to  a  neoplasm.     Agents  directed  to  the  removal  of  the  scybala  may 


220     BIOLOGY  OF  TUMORS  AND  GENERAL  CLINICAL  CONSIDERATIONS 

exclude  them  as  a  factor.  Inflammatory  processes  have  s3'mptoms  of 
their  own — pain,  tenderness,  rise  of  temperature,  and  characteristic 
changes  in  the  leukocyte  count.  Each  tumor  likely  to  be  confused  with 
such  conditions  has  individual  characters  that  count  in  the  diagnosis. 

To  be  able  to  name  a  tumor  correctly  is  of  little  use  unless  the  varia- 
tions within  the  class  can  be  correctly  interpreted.  To  identify  a  tumor 
as  a  carcinoma,  for  instance,  is  of  little  use  if  the  kind  of  carcinoma, 
its  rate  of  growth,  duration,  extent,  and  the  state  of  the  patient  are 
not  fully  understood.  In  every  case  of  tumor,  therefore,  the  most 
painstaking  study  should  be  made.  It  is  in  this  way  only  that  the 
clinician  learns  to  understand  the  slighter  points  of  difference  in  tumors. 
The  problem  of  diagnosis  can  best  be  studied  under  two  heads,  clinical 
and  laboratory. 

Clinical  Diagnosis. — The  clinical  diagnosis  is  a  judgment  based  on 
all  data  which  can  be  obtained  from  the  history  of  the  case,  from  the 
examination  of  the  patient  in  general,  and  of  the  tumor  m  particular. 
In  general,  it  should  include  all  those  methods  applied  to  the  diagnosis 
of  anv  other  disease. 

History  of  Case. — The  record  of  a  patient  should  comprise  not  only 
data  relative  to  the  tumor,  but  should  take  into  account  the  patient 
as  well.  Certain  points  are  of  particular  importance,  and  the  fullest 
information  should  always  be  sought.  In  all  cases  a  record  of  the 
previous  course  of  the  tumor  is  of  importance.  Sometimes,  it  is  true, 
the  history  can  be  read  from  the  appearance  of  the  tumor;  but  even 
the  simplest  problems  are  subject  to  error  and  every  detail  should 
always  be  taken  into  consideration.  The  data  should  be  made  a  matter 
of  record.  The  order  in  which  information  is  obtained  is  a  matter  of 
indifference,  but  the  following  is  suggested  as  natural  and  convenient: 

Jge  of  the  Patient. — The  age  of  the  patient  is  never  in  itself  decisive, 
but  it  is  often  of  great  confirmatory  value.  Certain  tumors  (teratomas, 
certain  cysts,  nevi)  are  usually  present  at  birth  or  appear  at  an  early 
age.  Other  tumors  are  most  frequently  seen  in  earl}^  Hfe  (sarcomas), 
others  in  middle  life  (myomas),  and  others,  finally,  at  an  advanced  age 
(carcinomas).  No  fixed  time,  of  course,  exists  for  the  appearance  of 
any  particular  tumor,  but  the  general  direction  of  inquiry  is  frequently 
indicated  by  the  age  of  the  patient.  Furthermore,  if  a  specific  tumor  is 
diagnosticated,  the  general  prognosis  may  be  influenced  b^'  the  age  of 
the  patient;  for  example,  carcinoma  occurring  at  an  earh'  age  is  apt  to 
be  especially  malignant. 

General  Health. — The  state  of  the  patient's  health  at  the  time  of 
observation,  must  be  noted.  If  it  is  impaired,  the  cause  must  be  deter- 
mined; for  the  fact  that  the  patient  has  a  tumor  does  not  prove  that 
the  impaired  health  is  due  to  it.     Thus  a  patient  w^th  a  fibroma  of  the 


CL/MC./L   Pl./(;\OS/S  OJ    ri  MORS  221 

uterus  nia\  have,  for  example,  a  concurrent  nephritis  or  pernicious 
anemia,  either  one  ot  which  would  seriously  affect  the  health  indepen- 
denrl\  ot  rhe  riiinor.  ( )rlu  i  diseases  beinj^  excluded,  the  tumor  itself 
may  cause  the  decline  m  health  m  different  ways — b\'  its  inherent  nature, 
that  is,  its  mahunancy;  or  by  accidents  which  attend  its  growth;  or 
horh  hictors  nuiy  be  combmed. 

riuis  a  Hbroma  of  rhe  uterus  ma\'  cause  hemorrhage  and  in  this 
wa\  affect  the  general  health.  A  carcinoma  of  the  uterus  ma\  pro- 
duce cachexia,  and  at  the  same  time  hemorrhage  ma\'  still  further 
reduce  the  patient.  Kven  worry  about  a  recently-  discovered  tumor 
may  cause  deterioration  of  health  such  as  is  sometimes  seen  when  a 
patient  regards  a  benign  tumor  of  the  breast  as  malignant. 

Duration. — The  most  important  question  which  the  histor\-  must 
answer  is.  How  long  has  the  tumor  lasted .'  Upon  this  depends  large!)' 
not  only  the  determination  of  its  nature,  but  also  the  prognosis.  Great 
care  must  be  exercised  in  accepting  the  patient's  statement,  for  obvioush- 
the  duration  of  the  tumor  will  be  dated  from  the  time  of  discovery,  and 
this  is  often  made  after  some  injury  which  leads  the  patient  to  examine 
the  part  affected. 

Thus,  frequentl}"  in  adenoma  of  the  breast  an  injur\"  ma\'  cause  the 
patient  to  discover  a  growth  of  considerable  size,  and  if  the  surgeon 
accepts  the  patient's  statement  he  may  assume  that  the  tumor  is  of 
a  rapidly  growing  variety.  Even  when  the  rate  of  growth  has  been 
found  to  be  rapid,  a  conclusion  must  not  be  made  at  once  that  the 
growth  is  malignant.  The  sudden  increase  in  size  ma\'  be  due  to  some 
change  in  a  benign  tumor.  Edema  in  a  myoma  of  the  uterus  ma\-  cause 
a  sudden  enlargement  which  might  lead  to  the  erroneous  conclusion 
that  a  so-called  sarcomatous  degeneration  had  taken  place;  or  a  hemor- 
rhage into  the  interior  of  a  benign  tumor  (lipoma,  fibroma,  or  th\roid 
cyst)  ma\'  cause  it  to  enlarge  suddenly.  Similar  accidents  in  the  course 
of  moderately  malignant  tumors  may  lead  to  a  mistaken  diagnosis  of 
excessive  malignancw  Inflammator\'  infiltration  about  a  malignant 
tumor  may  simulate  rapid  growth,  the  nature  of  which  becomes  apparent 
when  the  exudate  is  absorbed.  On  the  other  hand,  a  rapid  enlarge- 
ment should  always  be  regarded  of  grave  moment  until  it  is  shown 
bevond  doubt  to  be  accidental. 

Family  History. — As  previously  stated,  it  is  questionable  whether 
heredity  has  any  considerable  influence  in  the  production  of  tumors; 
however,  other  diseases  in  which  an  hereditary  predisposition  exists 
may  simulate  tumors.  This  is  particularly  true  of  tuberculosis,  and 
the  .presence  of  a  famil\"  predisposition  to  this  disease  should  caution  us 
not  to  mistake  a  tuberculoma  for  a  sarcoma,  or  a  tuberculous  ulcera- 
tion  for  a   carcinoma.      The   mistake   made   in   diagnosticating  s\'philis 


222     BIOLOGY  OF  TUMORS  AND  GENERAL  CLINICAL  CONSIDERATIONS 

as  some  other  tumor  has  been  on  occasion  so  frightful  as  to  caution 
us  to  consider  this  disease  in  the  vast  majority  of  tumor  cases,  and  the 
consideration  of  hereditary  influences  is  often  of  aid  in  obscure  cases. 
A  complete  history  of  the  patient's  antecedents,  therefore,  should  be 
recorded. 

Pain. — Pain  in  tumors  may  be  due  to  the  pressure  upon  a  nerve 
by  an  expanding  tumor  or  to  the  inclusion  of  a  nerve  by  an  infiltrating 
tumor.  The  pain  varies  with  the  location  and  character  of  the  growth, 
which  are  at  times  factors  of  importance  in  diagnosis.  Usually,  pain 
in  an  infiltrating  tumor  appears  late  and  indicates  that  a  considerable 
degree  of  invasion  has  already  taken  place.  Pain  may  also  be  the  result 
of  secondary  factors.  Infection  in  a  tumor  may  give  the  usual  pain  of 
an  inflammatory  process.  Accidental  pain  may  be  referred  to  a  tumor 
when,  in  fact,  no  relation  exists.  The  greatest  care  is  necessary,  there- 
fore, in  interpreting  the  significance  of  this  symptom. 

Injury. — The  history  of  injury  preceding  a  tumor  may  be  of  impor- 
tance in  two  ways;  it  may  indicate  that  the  tumor  is  inflammatory 
in  character,  or  it  ma}^  indicate  that  the  tumor  belongs  to  that  class 
which  not  infrequently  follows  trauma,  as  sarcoma.  On  the  other 
hand,  an  injury  occurring  in  the  course  of  development  of  a  tumor 
may  cause  it  to  change  its  character;  a  previously  slow  growing  tumor 
may  begin  to  grow  rapidly  (thyroid,  parotid);  a  benign  growth  may 
be  caused  to  degenerate  (myxoma,  lipoma);  a  quiescent  tumor  may 
suddenly  burst  out  in  malignant  development  (papillomas,  pigmented 
moles).  A  tumor  may  be  wrongfull}^  attributed  to  an  injury  when 
the  trauma  has  served  merely  to  attract  the  patient's  attention  to  a 
previously  unrecognized  condition.  A  patient  may  wilfully  misrepre- 
sent conditions  in  order  to  make  a  claim  for  injury.  The  result  of  the 
actual  injury  may  simulate  a  tumor;  for  instance,  exuberant  callus 
or  extensive  induration  about  an  infection  may  raise  the  question  of 
beginning  sarcoma. 

Physical  Examination. — The  physical  examination  of  a  tumor  miay 
be  divided  in  the  same  manner  as  physical  examination  of  the  chest, 
or  heart,  namely,  inspection,  palpation,  auscultation,  and  percussion, 
the  last  two  being,  however,  of  but  occasional  use. 

Inspection. — The  first  point  to  note  is  the  region  of  the  body  occu- 
pied by  the  tumor.  When  we  have  determined  from  which  tissue  a 
tumor  springs  we  have  made  the  greater  part  of  a  diagnosis.^  When 
we  can  say  that  a  tumor  has  grown  from  such  and  such  tissue  we  may 
be  certain  that  it  follows  the  type  of  that  tissue.  This  is  true  of  all 
primary  tumors.     Therefore,   by  noting  the  location  of  the  tumor  it 

^  Liicke,  AUg.  Chir.  Diagnostik  des  Geschwiilste,  Volkmann's  Vortrage,  No.  97. 


riiYsicii.  i:\.iMi\,iri()\  oi-  re  mors  '1X\ 

IS  tutiiunil)  possiMr  to  phut-  II  ;it  oiuc-  uiiliin  ;i  ri-lati\fly  narrow 
i;i()iip.  I  his  IS  |iaiiKulail\  tiiu-  ot  tuiiiors  arising  from  fetal  niis- 
plactnunts  whuh  air  situatrcl,  of  course,  in  the  hnes  of  the  fetal  folds. 
This  iiuliulcs  tkiniouis,  hiaiuhiofjenic  c\'sts,  and  tumors  derived  from 
aberrant  t^lands.  ()rlur  tumors  while  less  characteristic  in  situation, 
still  Ikixc-  nlati\il\  dcHniti-  areas  of  predilection.  1  his  is  ]')ai  ricularK' 
true  for  carcinomas  in  certain  orfi;ans  lip,  breast,  uterus,  stomach; 
for  lipomas  in  the  region  of  the  neck  and  shoulders;  and  for  sarcomas 
at  the  joint  extremities  of  the  long  bones. 

Relation  to  the  Surrounding  Tissue. — Frequently,  a  tumor  displaces 
anatomical  parts  which  are  easily  recognized  by  inspection.  1  his  mav 
give  a  clue  to  the  nature  of  the  tumor,  and  the  point  of  origin  as  well. 
For  instance,  a  tumor  of  the  neck  when  growing  superficially  covers 
the  sternomastoid,  but  when  growing  from  the  deeper  tissues  it  pushes 
this  muscle  to  one  side.  Similar  phenomena  may  be  observed  in  almost 
any  region  of  the  bodw 

Color. — The  color  of  a  tumor  ma)'  give  knowledge  of  the  most  varied 
and  important  significance.  A  cystic  tumor  ma\'  indicate  its  nature 
b\'  a  bluish  or  yellowish  color,  a  lipoma  b}'  a  \ellowish  color,  a  malig- 
nant tumor  by  a  reddened  surface,  caused  b}'  vascular  activity'.  Ihis 
activity  may  be  due  to  invasion  of  the  skin  by  an  infiltrative  growth, 
or  to  vessels  which  dilate  m  response  to  the  excessive  requirement 
for  nutrition  b\-  the  underlying  tumor.  A  whitish  glistening  surface 
mdicates  an  expansile  tumor  of  relatively  rapid  growth  in  which  the 
skin  does  not  partake.  This  is  particularh'  to  be  noted  in  benign  c\sts. 
The  character  of  vascular  tumors  is  determined  b}'  the  color  of  the 
surface;  thus,  in  lymphangiomas,  the  surface  is  pale,  in  venous  tumors 
bluish,  and  in  arterial  tumors  red.  Other  tumors  characterized  by 
the  formation  of  pigment  (melanomas,  xanthomas,  etc.)  disclose  their 
nature  by  the  color  of  their  surface. 

Surface  Conformations. — The  surface  of  tumors  which  are  exposed  to 
direct  examination  is  covered  by  skin  or  mucous  membrane.  Expan- 
sile tumors  cause  no  change  except  that  brought  about  by  distention. 
In  the  infiltrating  type  the  overlying  skin  becomes  affected  in  one  of 
three  ways:  (i)  If  the  underlying  tumor  is  made  up  largely  of  fibrous 
tissue,  the  retraction  of  this  tissue  produces  a  dimpling  (carcinoma  of 
the  mamma);  (2)  newgrowths  ma}'  form  in  the  skin  b\'  extension  from 
the  mother  tumor  (carcinoma  en  cuirasse);  (3)  the  most  common  result 
is  ulceration  of  the  overlying  surface  caused  by  invasion  of  the  new 
growth  (fungating  tumors).  The  ulcerated  surface  varies  much  in 
appearance  according  to  the  nature  of  the  tumor  beneath.  Suppurating 
processes    are    frequently    implanted    upon    the    tumor,   and    then    the 


224     BIOLOGY  OF  TUMORS  AND  GENERAL  CLINICAL  CONSIDERATIONS 

resulting  condition  depends  upon  the  character  of  the  infecting  organism 
plus  the  character  of  the  tumor. 

Forms  of  Tumors. — The  external  forms  of  tumors  vary  withm  wide 
limits,  and  if  correctly  interpreted  may  lead  to  a  surmise  of  the  nature 
of  the  neoplasm. 

Pedunculated  tumors  are  usually  expansile  in  growth,  and  therefore 
usually  benign.  Tumors  protruding  prominently  from  the  surface  with 
a  well-marked  outline  are  likewise  usually  benign,  and  mildly  malignant 
tumors  of  slow  growth  often  assume  this  form.  Elevated  tumors  which 
gradually  terminate  in  the  surrounding  tissue  are  most  likely  malignant. 
This  probability  is  much  heightened  if  the  surface  is  bosselated.  Tumors 
may  present  ulcerations  as  their  most  prominent  feature.  Ulceration  is 
usually  due  to  participation  or  invasion  by  the  tumor,  which  indicates 
malignancy.  Benign  tumors,  when  the  surface  is  subjected  to  irritation 
or  traumatism,  may  ulcerate;  but  in  these  the  extraneous  cause  of  ulcer- 
ation is  at  once  apparent.  The  habit  of  carefully  noting  the  external 
form  of  tumors  is  valuable  chiefly  as  a  means  of  excluding  enlargements, 
deformities,  or  diseases  which  may  stimulate  one  of  the  general  forms  of 
tumors. 

Palpation. — By  the  sense  of  touch  the  consistency  and  the  more 
intimate  anatomical  relation  to  the  surrounding  structures  may  be  deter- 
mined. Certain  precautions,  however,  must  be  observed  in  determining 
these  facts.  The  density  of  the  tumor  may  vary  from  soft  fluctuation 
to  stony  hardness.  The  fluctuation  of  cysts  may  be  readily  deter- 
mined if  the  wall  is  not  too  thick  or  the  tension  too  great.  Rapidly 
growing  cellular  tumors  may  simulate  fluctuation  because  of  the  amount 
of  fluid  in  the  tissue  (sarcoma),  or  because  the  substance  of  the  tumor 
is  semifluid  (lipoma,  myxoma). 

The  relation  of  the  tumor  to  the  surrounding  parts  may  be  detected 
by  testing  its  mobility.  Thus,  expansile  tumors  permit  the  skin  to  be 
lifted  and  the  tumor  to  be  pushed  about  upon  the  underlying  tissue. 
This  is  indicative  of  benignancy.  The  exceptions  are  those  tumors 
which  go  out  from  the  skin  itself,  to  which  they  are  then,  of  course, 
attached  (papillomas  and  wens).  Infiltrating  tumors,  on  the  other 
hand,  because  of  their  disposition  to  invade  surrounding  tissue,  are 
fixed.  Fixation,  therefore,  is  in  general  a  sign  of  malignancy.  It  is 
necessary  to  exclude  benign  tumors  which  have  become  secondarily 
fixed  by  inflammatory  processes. 

Palpation  may  serve  to  exclude  true  tumors  by  revealing  such  signs 
as  the  expansion  of  an  aneurysm,  the  crepitus  of  a  collection  of  gas, 
and  friction  rubs  about  the  tendons  and  bursae. 

Auscultation. — Auscultation  has  a  very  limited  application  in  tumor 
diagnosis,  but  is  useful  at  times  in  excluding  conditions  which  are  not 


Ki:.\i()i  .11.  or  rissii:  iok  dlkaostk:  I'l  r/'oses  22.") 

luophisnis,   siuh   ;is  ()\;iii;in  cwsrs,   \slmli   ^i\i-  icitaiii   tinrion   muiimiis 
\s  lull   tlu\    arc-  inoxiil.     Aiuui  \  snis  ni;i\    also  In-  diriitcd  l)\    rlu-  hiiiir. 

Laboratory  Diagnosis.  I  In  l;il>()!;it()r\  cxamiiKirioii  ot  rimiors  has 
two  ohiicts:  ill  I  lu-  uaiiiiiiL;,  ot  a  compuluiisivi-  knovvlcdf^c  o{  tin- 
sriiu-tui(.-  ami  litr  liis(()!\  of  tumors  m  ^iiuial;  2)  rlu-  diagnosis  ot 
rlu-  rumor  ar  liaiul.  I  lu-  oiu-  is  ruiulamt'iualiy  educative  in  piirp<jse, 
rlu-  orlui,  a  (.linical  rcsr.  ( )t  rluse  rwo,  rhe  former  is  incomparabi)' 
rlu-  more  impoiranr.  Ir  is  impossible  for  a  practitioner  to  make  a 
compi  rlunsiN  I-  cliiiua!  cliaL!,nosis,  uiiK-ss  he  is  m  possession  ot  such  a 
knowledge  of  tumor  morphology  and  life  tendency  that  he  is  able  to 
form  in  his  mind's  eye  an  accurate  picture  of  each  cell  and  tissue  of 
rhar  rumor  as  ir  exisrs  at  the  time  of  observation.  Such  a  knowledge 
can  he  gained  onl\  h\'  the  careful  painsrakmg  srudy  of  many  hundreds 
of  rumors.  Ir  presupposes  a  comiiieheiision  of  the  normal  anatomy 
of  the  bod\  in  order  to  know  the  peculiarities  of  growth  and  dissemi- 
nation which  rumors  assume  in  particular  tissues  and  regions.  It  is 
onh'  when  armed  with  such  knowledge  that  the  surgeon  is  able,  on  the 
one  hand,  to  diagnosticate  tumors  earl\'  when  they  are  within  reach  of 
his  therapeutics;  and,  on  the  other  hand,  to  avoid  a  useless  operation 
when  the\'  have  passed  the  stage  of  such  help. 

The  methods  of  procedure  differ  according  to  which  of  these  objects 
is  to  be  attained.  The  clinical  examination  is  made  just  before  or  dur- 
ing the  time  the  treatment  is  undertaken.  The  scientific  examination 
ordinarih'  is  undertaken  only  after  the  removal  of  the  tumor. 

Removal  and  Preservation  of  Tissue  for  Diagnostic  Purposes. — The  method 
to  be  used  depends  upon  whether  the  examination  is  undertaken  some- 
time before  the  treatment  is  instituted  or  in  the  operating  room  as 
a  preliminary^  step  to  the  operation.  In  either  case  the  microscopist 
must  assure  himself  that  he  has  obtained  tissue  from  the  border  of 
the  tumor.  It  is  here  alone  that  the  true  nature  of  the  tumor  can  be 
determined  in  all  cases.  It  is  likewise  necessary  to  obtain  a  section 
sufficienth'  large  to  permit  him  to  gain  a  thorough  knowledge  of  the 
topography  of  the  component  tissues.  In  solid  tumors  it  is  necessary 
to  make  an  incision  into  the  substance  of  the  tumor. 

A  suitable  section  of  tissue  having  been  obtained  for  examination, 
it  may  be  transferred  immediately  to  a  freezing  microtome  and  sec- 
tions cut  at  once,  or  the  tissue  may  be  placed  for  a  few  minutes  in  lo 
per  cent,  formalin  and  then  frozen.  Experienced  men  make  excellent 
sections  bv  this  method,  and  sections  may  be  had  in  five  to  fifteen  minutes 
after  the  tissue  is  removed.  If  a  tissue  is  to  be  transported  to  a  labora- 
tory for  examination,  it  should  be  placed  in  4  to  10  per  cent,  formalin 
in  order  that  frozen  sections  ma}"  be  made  as  soon  as  it  reaches  the 
laborator\".  Tissue  preserved  in  alcohol  cannot  be  frozen,  but  the  rapid 
15 


226     BIOLOGY  OF  TUMORS  AND  GENERAL  CLINICAL  CONSIDERATIONS 

paraffin  method  may  be  applied  with  satisfactory  results.  Sections 
may  be  made  in  twenty-four  hours  by  this  method.  Many  expert 
clinicians  have  sections  of  the  tumor  about  to  be  operated  upon  examined 
as  a  routine  measure,  others  only  in  the  more  obscure  cases.  The  pre- 
ceding presents  the  generally  accepted  practice  of  the  present  time. 
Personally,  I  do  not  believe  that  diagnostic  section  is  justifiable,  cer- 
tainly not  unless  the  operator  is  prepared  at  once  to  institute  the  proper 
treatment  as  soon  as  the  diagnosis  is  made.  Even  when  followed  by 
immediate  operation,  there  is  evidence  that  the  chances  of  cure  are 
lessened  by  the  removal  of  a  diagnostic  section. 

The  value  of  a  diagnosis  at  the  operating  table  is  inversely  propor- 
tional to  the  knowledge  of  pathology  possessed  by  the  surgeon  and 
directly  proportional  to  the  skill  of  the  pathologist.  Thus  a  surgeon 
trained  in  pathology  will  very  rarely  have  need  for  a  microscopic  diag- 
nosis in  the  operating  room,  while  the  unskilled  may  find  such  an  exami- 
nation useful  in  the  majority  of  cases.  On  the  other  hand,  unless  the 
pathologist  be  really  skilled  his  presence  is  worse  than  useless.  A  good 
pathologist  is  of  great  use  to  the  unskilled  surgeon.  If  both  are  un- 
skilled, their  combined  skill  but  commits  a  travesty  on  science  that 
makes  so  many  case  reports  such  sad  reading.  At  best,  all  that  the 
operator  can  gain  from  a  pathologist  under  such  circumstances  is  a 
name  for  the  disease,  which  is  a  vastly  different  matter  from  the  broad 
comprehension  which  can  be  gained  only  by  constant  journeyings 
between  the  operating  room  and  the  laboratory. 

When  a  tumor  has  been  removed  its  subsequent  treatment  for 
preservation  and  examination  will  depend  upon  the  size  and  character 
of  the  tumor.  If  the  tumor  is  to  be  preserved  as  a  museum  specimen, 
it  should  be  placed,  immediately  after  the  removal  of  small  sections 
for  microscopic  examination,  into  KaiserHng's  solution.  If  the  tumor 
is  small  it  may  be  placed  at  once  in  formaHn  or  Zenker's  solution. 

When  a  detailed  microscopic  examination  is  to  be  made  it  is  desirable 
to  place  sections  in  several  kinds  of  preserving  fluids.  If  the  tissue 
removed  is  from  the  nervous  system,  it  should  be  preserved  in  some 
chrome  fluid  (preferably  Miiller-formahn),  in  order  that  the  various 
specific  nerve  stains  may  be  subsequently  employed.  In  tumors  in 
which  a  differentiation  between  myomas  and  fibromas  is  likely  to  be 
difficult  a  fixation  of  thin  sections  in  Zenker's  fluid  is  particularly  desir- 
able in  order  that  Mallory's  stain  may  be  employed.  It  is  necessary 
to  examine  sections  from  various  parts  of  the  tumor. 

The  macroscopic  appearance  of  the  tumor  will  enable  the  competent 
examiner  to  determine  in  what  portions  of  the  growth  variations  in 
tissue  type  will  be  found.  It  is  only  by  examining  numerous  sections  that 
a  comprehensive  notion  of  the  structure  of  the  tumor  can  be  obtained, 


PROG  SOS  IS  (J  I    r  I  MORS  211 

btcausf  tumors  \ai\'  in  stiiutun  m  diHiiiiu  parts.  I'or  instance, 
a  tumor  showing  Hhrous  tissue  in  one  parr  ma\  show  Hbrosarcomatous 
tissue  in  anotlur,  or  a  slowly  j^rowin^  carcinoma  may  show  fibrous 
tissue  alone  over  a  considerable  space,  and  if  care  is  not  taken  the  car- 
cinomatous elements  mi<;ht  be  entirel)'  overlooked. 

In  makin<i;  a  caietui  study  of  a  tumor  it  is  desirable  to  make  a  rouj^h 
sketch  of  the  tumor  as  it  is  removed,  in  order  that  it  ma\'  be  subse- 
quentl\-  determined  from  what  region  a  given  microscopic  section  has 
been  taken.  Ihe  original  tumor  as  well  as  the  various  slides  should 
be  carefulh'  labelled,  bearing  the  name  of  the  patient,  the  date  of 
removal  and  the  method  of  preservation,  or,  better  still,  by  a  number 
referring  to  a  record  book  where  these  data  have  been  recorded. 

Special  Methods. — The  surgeon  should  not  content  himself  with  the 
routine  e.xamination  with  simple  stains,  but  should  familiarize  him- 
self with  the  detection  of  the  finer  changes  which  tinctorial  chemistr\- 
makes  possible.  In  general,  a  simple  hematoxylin-eosin  stain  is  the 
most  useful,  and  should  always  be  used  to  gain  a  knowledge  of  the  general 
structure  of  the  tumor.  Other  stains,  or  a  specific  technique,  ma\"  be 
required  to  clear  up  special  points.  Thus  the  diflPerentiation  between 
fibrous  tissue  and  muscle  may  require  special  stains  (van  Gieson's 
fibrous  tissue  stain  or  Mallory's  myoglia  stain);  a  special  stain  for 
nerve  tissue  ma\'  in  some  instances  require  teased  or  shaken  specimens 
in  order  to  demonstrate  the  reticulum,  etc.;  or  the  differentiation  of 
pseudo-cell  nests  from  cancer  nests  (e.  g.,  epithelioma  of  the  skin  or 
cervix)  may  require  a  serial  section.  In  the  study  of  glandular  tumors 
likewise  serial  section  maji'  be  required  in  order  to  determine  the  direc- 
tion in  which  a  section  has  passed  through  the  gland. 

Prognosis.^  —  According  to  their  biological  behavior,  tumors  have 
been  classed  as  benign  and  malignant.  No  hard  and  fast  lines  can 
be  drawn,  but  the  majority  of  benign  tumors  present  inconveniences 
rather  than  dangers.  It  must  be  constantly  remembered,  however,  that 
benign  tumors  may  cause  death  of  the  patient  in  various  ways:  (i) 
B\-  pressure  on  important  parts  (brain,  ureters  in  pelvic  tumors,  lungs, 
and  the  great  vessels  in  intrathoracic  tumors,  etc.);  (2)  by  secondary 
infection  ('lipomas,  myomas);  (3)  by  necrosis  from  obstruction  ot  the 
blood  supply  (ovarian  cyst,  myomas);  (4)  by  occluding  important 
channels,  such  as  the  trachea  (thyroid  tumors),  or  intestinal  canal 
(polypoid  tumors  of  the  lumen,  or  by  pressure  of  large  abdominal  tumors 
from  without);  (5)  by  pressure  upon  important  nerves  (tumors  of  the 
mediastinum  or  neck).     Also  certain  benign   tumors  may  menace  the 

'  For  an  excellent  statement  of  the  theor}-  of  prognosis  see  Andrews,  Ann.  Surg., 
1905,  xlii,  903. 


228     BIOLOGY  OF  TUMORS  AND  GENERAL  CLINICAL  CONSIDERATIONS 

individual  by  malignant  change.  Sarcomas  of  the  uterus  may  become 
implanted  upon  myomas;  the  benign  tumors  of  the  breast  may  become 
malignant;  from  melanotic  tumors  of  the  skin  malignant  tumors  may 
result.  A  few  border-land  cases  have  been  reported  in  which  tumors 
structurally  benign  have  formed  metastases  in  vital  organs  and  thus 
destroyed  the  life  of  the  individual  (myoma  or  chondroma  forming 
secondary  nodules  in  the  lung).  . 

The  expression  "malignant  tumor,"  as  usually  interpreted,  has  to 
do  more  with  the  disposition  of  the  tumor  to  local  recurrence  and  to 
metastasis  than  to  its  disposition  to  cause  the  death  of  the  patient. 
As  above  indicated,  a  tumor  biologically  benign  may  menace  the  life  of 
the  patient  in  many  different  ways.  The  location  and  circumstances  of 
growth  are  often  quite  as  important  to  the  welfare  of  the  patient  as 
the  biological  character  of  the  tumor. 

On  the  other  hand,  tumors  ordinarily  malignant  may  be  of  such  slow 
growth  that  they  are  practically  benign  (basal-celled  epitheliomas  of  the 
face).  As  a  group,  the  malignant  tumors  tend  to  destroy  life  because 
of  their  rapid  cell  proliferation,  by  their  local  recurrence,  and  by  metas- 
tases. They  may  also  kill  in  the  same  manner  as  benign  tumors,  by 
compression  or  secondary  degeneration.  But  they  have  the  additional 
tendency  of  directly  invading  important  structures  with  their  infiltrat- 
ing growth.  Thus  carcinoma  of  the  uterus  may  invade  the  parame- 
trium and  involve  and  obstruct  the  ureters,  thus  destroying  the  function 
of  the  kidney  when  the  tumor  itself  is  quite  small.  The  disposition  of 
the  tumor  to  ulcerate  may  act  perniciously  in  several  ways.  The  ulcera- 
tion may  cause  death  by  perforation  (intestinal  canal  and  esophagus), 
or  the  invasion  ma}^  involve  important  vessels  and  cause  death  by  hem- 
orrhage (carcinomas  of  stomach,  esophagus,  and  larynx).  The  ulcer- 
ating process  may  permit  microorganisms  to  enter  the  body  and  cause 
extensive  sloughs,  or  the  .local  suppuration  may  poison  from  absorption 
of  the  toxins. 

A  prognosis  of  the  malignant  tumors  then  depends  not  alone  upon 
the  biological  disposition  of  the  tumor  to  recur,  elaborate  poisons, 
and  form  metastases,  but  also  upon  the  size,  location,  and  tendency 
to  degenerate.  The  importance  of  these  facts  is  to  remind  us  again 
that  much  more  than  the  simple  naming  of  a  tumor  is  necessary  before 
we  are  able  to  outline  an  intelligent  line  of  treatment  or  make  a  trust- 
worthy prognosis. 

Treatment. — When  the  nature  of  a  tumor  is  understood  the  require- 
ments necessary  to  rid  the  host  of  the  growth  are  clear,  though  we  may 
not  be  able  to  accomplish  them.  It  is  necessary  only  to  determine 
the  exact  biological  character  and  its  topographical  relations.  It  is 
optimistically   stated   that  at  some   period   of  their  growth   all   tumors 


rRE.iTMEsr  or  ri  mors  220 

are  local,  ami  ifii  iiiox  (.il  a  iiin-  will  nsiilt;  hut  ir  miisr  ht-  assuiiitc!  in 
infilnarin<i  runiois  that  fxttiision  lias  alr(acl\  taktii  plact-.  When  a 
runioi  IS  known  ro  ht-  hioloLiicallx  mali^,naiu,  <>prran\f  rriatnunr 
is  not  indiiartil  until  it  has  lutn  ck-nionstrattcl  that  tin-  (.ntirt.-  growth 
can  he  icniovt'cl.  This  recjuires  an  examination  of  the  surroundni^ 
tissue  and  of  other  locations  where  metastases  may  form;  for  instance, 
the  l\niph  nt)dcs  in  carcinoma  and  distant  parenchymatous  organs 
(li\"er,  lungs,  etc.)  in  sarcoma.  These  general  principles  are  modiHed 
h\  iiian\'  factors,  which  differ  not  only  for  each  tumor  group,  hut  tor 
each  variety  and  for  the  region  which   they  occupy. 

Benign  tumors  can  usually  be  shelled  out  ot  their  capsule  'lipomas, 
fibromas,  etc.),  or  their  base  easily  circumscribed  b\-  the  incision  (papil- 
loma). The  old  delusion  as  to  the  fre(|uenc\'  of  degeneration  of  benign 
tumors  has  given  rise  to  much  needless  mutilation  "in  order  to  be  on 
the  safe  side,"  and  is  an  expression  of  an  uncertain  comprehension  ol 
the  character  of  the  tumor.  When  the  nature  of  the  tumor  is  exactly 
determined,  the  technical  requirements  can  be  clearly  defined.  Often 
a  clear  determination  of  the  nature  of  a  tumor  is  difficult,  but  the  dispo- 
sition of  surgeons  to  justify  a  needlessly  radical  operation  under  this 
cloak  has  done  much  to  retard  the  clinical  side  of  oncological  science. 
The  rules  for  operation  in  the  different  biological  t\pes  ot  tumors  may 
be  stated  in  a  broad  wa\',  which  can  be  narrowed  only  by  a  specific 
knowledge  of  the  concrete  problem  at  hand.  The  indications  for  the 
removal  of  benign  tumors  are:  (i)  For  cosmetic  reasons;  (2)  when 
important  structures  are  .indirectly  involved  by  pressure;  (3)  when 
secondar\'  degeneration  is  present  or  impending  (suppuration,  necrosis, 

etc.)- 

The  operative  indications  for  malignant  tumors  are:  (i)  The  removal 
of  the  tumor  and  its  infiltrating  borders;  (2)  the  accessible  areas  of 
possible  metastases.  The  indications  present  for  benign  tumors  all 
obtain  in  the  malignant,  but  in  the  latter  they  are  lost  in  the  presence 
of  the  one  great  problem  of  the  removal  of  the  limitless  growth  of  the 
malignant  cells.  The  extent  of  tissue  to  be  removed  must  be  decided 
at  the  operating  table;  the  decision  demands  a  knowledge  of  the  kind 
and  life  history  of  the  tumor.  The  recognition  of  the  probable  situa- 
tion of  metastasis  is  a  problem  in  anatomy.  Presentation  of  the  details 
of  this  general  plan  must  be  deferred  to  the  section  on  the  different 
t\pes  of  tumors  when  situated  in  particular  regions. 

Palliative  Treatment. — When  the  operative  cure  ot  a  tumor  is  no 
longer  possible,  a  number  of  procedures  are  available  for  the  relief  ot 
certain  symptoms.  The  removal  of  the  tumor  may  be  justified  to 
save  the  patient  pain  or  to  limit  an  infection,  though  inaccessible  metas- 
tases ma}'  be  present.     Channels  closed  b}'  the  invasion  ot  the  tumor 


230     BIOLOGY  OF  TUMORS  AND  GENERAL  CLINICAL  CONSIDERATIONS 

may  be  relieved  by  artificial  openings  beyond  the  point  of  obstruction 
(tracheotomy  for  carcinoma  of  the  larynx,  gastrostomy  for  tumors 
of  the  esophagus,  colostomy  for  tumors  of  the  rectum,  etc.)-  When  no 
form  of  operative  treatment  is  possible,  the  resources  of  the  surgeon 
are  still  not  exhausted.  Various  methods  may  be  employed  for  the 
rehef  of  the  patient's  mind  and  body.  Injections  of  alcohol  may  accom- 
plish both  results.  The  x-ray  treatment  is  of  use  in  allaying  pain  and 
in  many  cases  in  inhibiting  the  growth  of  the  tumor.  When  nothing 
else  can  be  done  the  suffering  of  the  patient  may  be  relieved  by 
morphine. 


c  II  A  1*  1  1-:  k    x  x 
TUMORS  ov  riii-:  cranium 

'I'ni';  c-iaiiial  rc{;ion  may  be  calKtl  tin-  oiicoIo^k  al  imiscum  ot  the 
hoch  ,  since  nearly  every  known  tumor  ma\  he  encoimteied  here  either 
as  a  primar\-  «i;r()\vth  oi"  as  a  metastasis  of  a  growth  in  a  distant  or^an. 
The  Hfe  hist()r\-  of  the  neophisms  which  occur  in  this  region  is  better 
known  than  that  of  those  of  other  regions  because  of  its  exposed  posi- 
tion. The  early  detection  of  tlieir  presence  hy  the  patient  leads  him 
to  seek  advice  early,  and  he  is  usually  able  to  give  a  fairl\-  accurate 
account  of  the  growth.  Notwithstanding  these  favorable  factors,  the 
results  of  the  treatment  of  malignant  tumors  of  the  head  have  not 
been  as  good  as  the  conditions  would  seem  to  warrant.  Often  for  cos- 
metic reasons  the  radical  treatment  indicated  is  not  carried  out  with 
the  same  freedom  as  in  less  exposed  parts  of  the  bod\-.  Timidity  in 
technique  is  frequently  due  to  an  uncertain  diagnosis  in  the  early  stages 
of  the  disease.  The  suspicion  of  the  operator  that  he  may  be  dealing 
with  a  benign  lesion  leads  to  a  more  conservative  procedure  than  would 
be  employed  if  the  malignant  character  of  the  neoplasm  were  full\- 
appreciated. 

Wens  (Atheromas)  (Fig*.  143). — These  most  frequently  affect  women 
past  middle  age,  and  are  very  rare  in  the  developmental  period  of  lite. 
The  scalp  is  the  most  susceptible  area,  nearly  one-half  of  all  wens  occur- 
ring in  this  region.  The\'  are,  in  fact,  the  most  frequent  tumor  of  the 
scalp.  This  frequency  is  due  to  the  great  number  of  sebaceous  glands 
and  to  the  unsanitary  condition  of  many  scalps. 

Wens  are  formed  by  a  collection  of  sebaceous  material  and  desqua- 
mated epithelium  within  the  sebaceous  glands,  due  to  occlusion  of  the 
ducts.  They  vary  from  the  size  of  a  pea  to  that  of  an  orange  or  even 
larger,  but  are  usually  not  larger  than  a  walnut.  The\-  are  usually 
globular  in  form  but  ma\-  be  bosselated  when  several  develop  in  close 
proximit\-  and  coalesce;  when  firm  constriction  bands  pass  over  a  single 
tumor,  it  may  be  pseudolobulated.  When  small  the\-  are  hard,  and  as 
the^•  grow  they  become  soft  and  pultaceous.  The  skin  covering  them 
is  usually  smooth  and  shin)-,  and  ma)-  be  bluish  from  venous  conges- 
tion. Hair  is  generalh-  absent  on  account  of  atroph\-  of  the  follicles 
caused  by  stretching  of  the  skin. 

Wens  are  often  peculiarl\-  striking  and   repulsive  deformities.      1  hey 


232 


TUMORS  OF  THE  CRANIUM 


are  intimately  attached  to  the  skin,  and  because  of  the  bony  base  upon 
which  they  rest  tend  to  project  outward,  and  in  some  cases  may  even 
become  pedunculated.  The}^  sometimes  extend  into  the  subcutaneous 
tissue,  but  never  extend  below  the  pericranium.  In  rare  instances 
they  become  detached  from  the  skin.  They  frequently  become  inflamed, 
and  suppuration  with  perforation  of  the  skin  may  follow.  After  dis- 
charging for  a  time  the  opening  closes  and  they  usually  refill,  only  to 
repeat  the  process.  The  suppuration  may,  however,  by  destroying  the 
lining  epithelium,  lead  to  a  spontaneous  cure.  On  the  other  hand,  a 
fistula  may  form,  or  occasionally  serious  suppuration  may  supervene 
by  extension  into  the  loose  surrounding  connective  tissue.  Prolonged 
irritation  sometimes  results  in  the  formation  of  epithelioma. 

Fig.  143 


Sebaceous  cysts. 


Diagnosis. — Wens  must  be  distinguished  from  dermoids,  meningoceles, 
and  serous  cysts.  From  the  dermoids  the}"  are  differentiated  by  their 
intimate  attachment  to  the  skin,  by  their  freedom  from  attachment 
to  the  pericranium,  by  their  location  elsewhere  than  over  the  fetal 
fissures,  and  by  the  fact  that  dermoids  are  frequently  first  observed 
during  adolescence,  while  wens  are  growths  of  later  periods  of  life.  From 
meningoceles  they  are  distinguished  by  their  freedom  from  attachment 


r  ii'ii.i.oM.is 


233 


to  tin  jHiiciiinium,  ;incl  h\  absence  of  pulsation  and  of"  compressibility. 
1  he  occasional  association  of  wciis  with  nuninjicjccles  should  not  be 
foriiottcn. 

Treatment.  Sinct-  they  arc  caused  b\'  excessive  secretion  of  the  hning 
cells,  the  cyst  wall  must  be  removed.  I  his  can  be  done  most  conveniently 
under  cocaine  or  quinine  anesthesia,  by  injecting  the  fluid  freely  about 
and  beneath  the  tumor.  In  this  way  the  surrounding  connective  tissue 
becomes  edematous  and  iHiniits  an  easier  enucleation.  If  the  tumor 
is  small,  the  incision  is  made  through  the  overlying  skin  down  to  but 
not  into  the  sac,  which  is  then  carefull\'  dissected  out.  In  moderate- 
sized  and  larger  tumors  an  elliptical  mcision  should  be  made  following 
the  margin  of  the  wen  where  the  skin  is  less  firniK'  attached,  and  the 


ic.  144 


Fibrous  papilloma  ot  the  scalp. 

sac  ma\  then  be  easily  dissected  awa\-.  Hemorrhage  may  be  con- 
trolled by  pressure  or  b}'  ligatures  of  fine  catgut.  A  few  sutures  in 
the  edge  of  the  wound  complete  the  operation.  Because  of  the  greater 
danger  of  infection,  v.  Bergmann  preferred  to  omit  sutures  entirely.  If 
the  tumor  is  alread}'  the  site  of  suppuration,  the  sac  must  be  removed 
piecemeal,  which  is  often  difficult  to  do  completely.  In  this  case,  at 
least,  sutures  should  be  omitted.  With  the  removal  of  the  sac  a  definite 
cure  is  obtained.  The  scalp  is  particularly  subject  to  infection,  and 
therefore  careful  asepsis  is  urged  in  this  otherwise  trifling  operation. 
Papillomas. — Papillomas  of  the  scalp  form  small  tumors,  from  the 
size  of  a  pea  to  that  of  a  hazelnut.  The}-  are  sharph'  circumscribed, 
sometimes  slightly   constricted   at  the   base   (Fig.    144).     Their  surface 


234  TUMORS  OF  THE   CRAXIUM 

is  roughened  by  numerous  filiform  projections.  They  are  intimately 
united  with  the  skin  and  move  with  it.  Histologically  they  are  com- 
posed of  fibrous  tissue,  with  a  thick  overh'ing  layer  of  epithelium.  They 
are  essentially  epithelial  warts,  and  occasionall}^  form  large  dense  pro- 
jections on  the  scalp.  They  are  pigmented  with  yellowish  or  brown 
shades,  and  often  on  the  temples  are  almost  black.  Fibrous  papillomas 
are  less  common.  They  are  covered  with  a  thin  layer  of  epithehum 
and  are  composed  of  fibrous  tissue  containing  masses  of  spherical  (em- 
bryonalj  cells.  These,  particularly  the  pigmented  varieties,  frequently 
give  rise  to  melanosarcomas  (Fig.   145).     They  ma}'  be  confused  with 

Fig.  145 


^-x 


Melanotic  papilloma  of  the  scalp,  with  metastasis  in  the  lymph  glands  and  neck. 

endotheliomas,  but  can  be  distinguished  from  them  by  their  papillo- 
matous surface.  These  tumors  usually  cause  disturbance  only  b}' 
interfering  with  the  ordinary  care  of  the  scalp,  but  are  sometimes  the 
starting  pomt  of  epitheliomas. 

Treatment. — They  are  best  treated  by  excision.  An  elliptical  incision 
is  made  through  the  entire  thickness  of  the  skin  because  of  the  deep 
attachment  of  the  growth.     The  defect  is  then  closed  with  sutures. 

Elephantiasis  Nervorum.^ — The  scalp  is  considered  to  be  the  seat 
of  this  lesion  in  about  one-third  of  the  cases,  the  temporal  region  being 
most  commonly  affected  (Fig.  146;.     Most  of  the  cases  occur  in  young 

1  Helmholtz  and  Gushing,  Amer.  Jour.  Med.  Sci.,  1906,  cxxxii,  355. 


r.l.l:l'll.l\ri.l  S  IS    \  I.  Kl  OKI   M 


28.-) 


adults,  hiir  tlu-  disease  is  soiiutiims  conjit-mral.  1  liere  is  often  a  family 
pieiiisposition.'  I'he  affecfion  usually  begins  as  a  tliickeniiifj;  (A  the  skin, 
Nvlu-nce  rlu-  term  "pachydermatocele"  was  applied  to  it  hy  Mott.-  As 
tile  ilisease  progresses  the  skin  saj!;s  over  the  side  of  the  head.  If  in  the 
teiiipoial  region,  it  tc  luls  to  displace  the  ear,  or  if"  m  the  frontal  refiion, 
ma\'  even  cover  the  face.  When  the  pendent  mass  is  lifted  b}'  the  hand 
the   displaced    organs   are   restored    to   their  normal    situations.      Mott 

Fi<;.   I  \t'< 


Elephantiasis  nervorum  of  the  temporal  retiion.     A  large  mass  had  been  removed 
from  the  temple  before  the  photograph  was  taken. 

described  this  mass  as  being  to  the  touch  like  the  dependent  breast,  the 
thickened  and  nodulated  nerves  suggesting  the  lobules  of  the  gland.  The 
characters  mentioned  above  will  hardly  permit  this  condition  to  be  mis- 
taken for  any  other.  A  hmphangioma  ma}'  present  a  slight  resemblance 
but  the  disposition  to  sag  is  absent. 


^  Feindel,  quoted  by  Helmholtz  and  Gushing. 
-Med.  Chir.  Trans.,  1854,  xxxvii,  156. 


236 


TUMORS  OF  THE  CRANIUM 


Treatment. — The  only  treatment  is  excision.  This  may  be  attended 
by  some  difficulty  because  of  hemorrhage.  Infection  is  prone  to  take 
place  in  the  loose  tissue.  When  the  disease  is  extensive,  several  sittings 
may  be  necessary  for  its  removal.^ 

Lipomas. — About  2  per  cent,  of  all  lipomas  occur  in  the  scalp.-  They 
occur  most  frequently  on  the  forehead  (Fig.  147),  37  out  of  54  cases 
according  to  Chipault.^  They  form  more  or  less  lobulated  tumors, 
except  when  in  the  temporal  region.  Here  they  are  situated  below 
the  aponeurosis  of  the  temporal  muscle  and  are  diffuse. 


Fig.  147 


Lipoma  of  the  loiehead. 

They  vary  in  size  from  a  hazelnut  to  a  hst,  and  occasionally  even 
form  enormous  tumors  which  hang  over  the  face  and  shoulders.  One 
case  is  reported  in  which  the  tumor  reached  from  the  forehead  to  the 
knees.     They  are  not  attached  to  the  skin,  but  are  frequently  fixed  at 


1  Billroth,  Arch.  f.  klin.  Chir.,  1869,  xi,  232. 

2  Grosch,  Deutsch.  Ztschr.  f.  Chir  ,  1887,  xxvi,  307. 
^  Traivaux  de  Neurologic  chirurgicale,  Paris,  1895. 


DERMOIDS  237 

ilu-  l>;isi  .  In  ilif  ()fii|)it;il  legion  tins  fixation  nsiilis  tioni  pioloii^a- 
rions  winch  tlu\  smd  out  ainoiii;  tin-  inusilcs  ol  tin-  tuck.  Over  the 
sc;ilp,  as  \.  l>iiL;inaini  |)oniti(l  out,  tlu\  ha\c  a  vei\'  intimate  relation 
with  the  ptiiostcum.  I'lhlciscn  ic^aidcd  thcif  periosteal  attachment 
as  t\  pical  ol  li|)onias.  (  )ii  ilu'  loiehead  rlu\  lie  in  the  f'at-fiee  con- 
lucriM-  tissue  hiiuath  tiu  muscle.  I'luie  is  tVeciuentU-  an  inhltration 
into  the  peiicianiuin  ahoui  their  periiiluiw  which  makes  it  appeal"  as 
thoutih  the  tumor  la\    in  a  (.Icpiession  in  the  hone. 

Diagnosis.  -Lipomas  differ  from  wens  in  that  the\  aie  unattached 
to  the  skin  and  ha\e  intimate  connection  with  the  peiiosteum.  'I'he\' 
ditter  from  dermoids  in  heing  located  elsewhere  than  at  the  sites  of 
fetal  clefts.  1  hey  are  also,  as  a  rule,  tumors  of  advanced  \'ears,  while 
the  dennouls  appeal"  in  early  life,  although  .Monnie  has  collected  a 
number  of  cases  of  congenital  lipoma.  He  emphasized  particular!)-  the 
fact  that  the\'  may  be  associated  with  meningoceles  and  may  obscure 
them,  especially  when  located  over  cranial  fissures.  This  association 
probably  forms  the  basis  for  this  author's  statement  that  lipomas  ma\- 
be  connected  with  the  dura.  The  infiltration  of  the  pericranium  about 
their  base,  as  mentioned  above,  sometimes  simulates  closely  the  osseous 
depressions  of  dermoids.  The  subfascial  (temporal)  lipomas  have  been 
mistaken  for  cold  abscesses  and  also  for  syphilitic  processes. 

Treatment. — Excision  is  the  only  treatment.  Their  removal  is  usually 
a  relatively  simple  matter  unless  lobulations  extend  into  the  surround- 
ing muscles.  In  such  cases  the  operation  ma)-  involve  some  difficult\-. 
Their  lobulation,  their  frequent  firm  attachment  to  the  periosteum, 
and  the  possibility  of  th"eir  association  with  intracranial  lesions  make 
them  little  suited  for  removal  under  local  anesthesia. 

Dermoids. — These  tumors  are  situated  in  the  natural  lines  of  junction 
of  the  developing  cranium,  and  are  common  in  the  temples,  orbit,  root 
of  the  nose,  more  rarely  over  the  mastoid.  They  are  sometimes  observed 
over  the  fontanelles,  particularly  over  the  great,  less  often  over  the 
glabellar  and  occipital.  Confusion  is  sometimes  caused  by  their  presence 
at  some  distance  from  the  natural  location  of  these  fetal  clefts.  Von 
Bergmann^  explains  this  discrepancy  b)'  assuming  that  they  become 
early  attached  to  the  bones,  and  as  the  bones  develop  the  tumors  are 
carried  with  them. 

They  form  smooth  hemispherical  elevations  over  which  the  skin 
is  freel)'  movable.  They  are  not  movable  upon  their  base  because 
of  the  intimate  association  with  the  periosteum.  Quite  regularl\-  the\- 
are  received  in  a  depression  of  the  bone.  The  depression  is  not  due  to 
atrophy  from  pressure,  but  to  failure  of  the  bone  to  develop,  since  the 

'  Handb.  d.  Pracr.  Chir.,  Band  i,  Enke,  Stuttgart.  1900. 


238  TUMORS  OF  THE  CRANIUM 

tumors  are  present  before  ossification  takes  place.  The  bone  ma\'  be 
entirely  absent,  so  that  a  portion  of  the  tumor  ma}'  project  into  the 
cranial  cavit3\  Dermoids  ma}"  escape  notice  during  the  earliest  period 
of  life,  but  the}"  are  frequently  seen  in  the  second  and  third  }"ears,  and 
are  particularly  likely  to  develop  rapidh"  about  the  time  of  pubert}\ 

They  contain  a  whitish  fatty  fluid  composed  of  fattil}"  degenerated 
epithelium,  cholesterm  crystals,  the  secretion  of  fat  and  sweat  glands, 
and  frequently  hair.  Sometimes,  however,  the  contents  ma}"  be  serous, 
due  to  the  fact  that  the  solid  elements  have  become  precipitated  on 
the  c}^st  wall;  the  cyst  contents  ma}'  become  hemorrhagic  from  traumatic 
rupture  of  the  bloodvessels.^ 

Diagnosis. — Dermoids  must  be  differentiated  from  wens  and  meningo- 
celes. From  the  former  they  ma}"  be  distinguished  by  their  non-attach- 
ment to  the  skm,  b}"  their  deep  attachment  to  the  periosteum,  and^ 
above  all,  by"  their  location  over  the  site  of  the  fetal  clefts.  Tumors 
which  occur  before  the  fifteenth  }"ear  are  dermoids  and  not  sebaceous 
cysts. 2  Wens  project  from  the  surface  as  spherical  tumors,  while  der- 
moids appear  as  hemispherical  tumors  because  their  bases  are  flattened 
and  are  set  in  the  periosteum  or  bone.  Dermoids  are  always  single^ 
while  wens  are  frequently  multiple. 

From  meningoceles  the}'  ma}'  be  differentiated  by  their  failure  to 
disappear  or  to  cause  s}'mptoms  of  increased  intracranial  tension  when 
pressed  upon.  Dermoids  when  projecting  into  the  skull  transmit  pulsa- 
tion from  the  brain,  and  aspiration  may  be  necessary  for  differentiation. 
It  must  be  remembered  that  the  mere  demonstration  of  the  presence  of 
a  clear  fluid  is  not  suflBcient  to  exclude  dermoid,  since  a  separation  of  the 
fluid  and  solid  elements  may  take  place,  as  has  been  stated  alread}", 
particularly  in  dermoids  which  have  remained  stationar}"  for  a  long 
time. 

Age  is  important  as  a  diagnostic  factor,  inasmuch  as  encephaloceles 
usuall}"  result  fatally  before  dermoids  ordinarily  become  objects  of 
clinical  observation.  The  location  of  the  tumor  is  of  great  importance 
in  the  diagnosis.  Dermoids  are  very  rare  in  the  occipital  region,  while 
encephaloceles  are  particularly  common  in  this  region.  Encephalo- 
celes, except  in  the  occipital  region,  are  never  encountered  in  the  mid- 
line of  the  cranium.^  When  the  anatomy  of  this  region  is  remembered, 
this  can  occasion  no  surprise.  In  order  for  brain  substance  or  meningo- 
celes to  appear  at  this  point,  a  failure  of  development  in  the  falx  cerebri 
would  be  necessar}".    A  failure  of  development  of  this  magnitude  occur- 

^  Fehleisen,  Deutsch.  Ztschr.  f.  Chir.,  1881,  xiv,  5. 
^  Chiari,  Ztschr.  f.  Heilk.,  1891,  xii,  189. 

^  Rathlef,  Zur  Casuistik  und  Diagnostik  der  epicraniellen  Dermoidcysten,  Dorpat, 
1876. 


.fXCIOM.IS  2.\U 

v\n^  so  t;irl\  in  cl(.\  rl()|>nunr  would  l)f  artt-ndcd  by  cerebral  anomalies 
which  could  1)1-  (.asiU  ditii  niiiicd  it",  indeed,  they  were  compatible 
with  life. 

Treatment.  Removal  is  usually  mdicatc-d  tor  cosmetic  reasons. 
This  m:i\-  freeiuenrl)-  be  accomplished  under  local  anesthesia,  but  their 
inrimate  attachment  to  the  periosteum  sometimes  makes  the  use  of 
a  general  anesthetic  desirable.  This  is  particularly  true  where  a  por- 
tion of  the  tumor  extends  into  the  cranial  cavit\'  and  the  use  of  a  peri- 
osteal elevator  or  bone-cutting  instrument  is  required  for  its  removal. 
When  the  tumor  is  in  direct  contact  with  the  meninges  there  is  a  line 
of  cleavage  which  permits  an  easy  separation.  In  all  instances,  there- 
fore, where  an  exact  differential  diagnosis  cannot  be  made  between  a 
dermoid  and  a  meningocele,  a  general  anesthetic  should  be  empk^ed, 
and  precautions  usuall\'  observed  in  brain  operations  should  be  taken.' 

Angiomas. — Simple  angiomas  are  most  frequently  seen  about  the 
temples  and  forehead,  but  the}'  occur  also  about  the  occiput  or  at 
the  root  of  the  nose.  They  are  usually  congenital  or  appear  soon  after 
birth.  The  cavernous  angiomas  are  likel\'  to  occur  at  the  occiput  or  on 
the  forehead.  Their  rate  of  growth  corresponds  to  the  rate  of  growth 
of  the  child.  Sometimes  they  disappear  spontaneously,  but  rapid  devel- 
opment frequently  takes  place,  particularh'  in  the  cavernous  type. 
Fatal  hemorrhage  has  occurred  from  their  accidental  rupture  or  from 
incision  made  under  a  mistaken  diagnosis. 

Cirsoid  aneurysms  (Fig.  148J  are  found  most  frequently  upon  the 
temples.  They  may  become  implanted  upon  nevi  or  ma\-  result  from 
trauma.  Thev  may  cause  .erosion  of  the  underl}ing  bone  or  ulceration 
of  the  skin  covering  them.  If  the}-  are  in  connection  with  vessels  of 
considerable  size  pulsation  may  be  perceptible  to  the  examining  linger 
and  the  patient  may  complain  of  the  constant  whirring  noise  produced 
by  the  blood  current. 

Treatment. — Simple  angiomas  ma\'  be  excised  when  small  or  ma\'  be 
treated  by  electrol}'sis.  The  latter  is  preferable  in  regions  where  scarring 
w^ould  be  objectionable.     Carbon  dioxide  snow  may  also  be  useful. 

Cavernous  tumors  of  the  scalp  ma}'  be  excised  when  their  size  per- 
mits. Mass  ligation  may  be  useful  if  the  base  can  be  easily  circum- 
scribed. Electrolysis  is  tedious  and  is  seldom  justified.  Peccioni, 
however,  recommends  it  in  all  cases  because  it  may  cure;  if  it  does 
not  cure,  subsequent  operation  is  made  safer.  If  excision  is  practised 
the  incision  should  be  at  least  one  centimeter  from  the  base.  A  narrower 
margin  might  endanger  large  sinuses  and  give  rise  to  dangerous  hemor- 
rhage  on    account   of  the    more    deepl}^    situated    sinuses   not   showing 

^  Fenger,  Clinical  Lecture,  November,  1893. 


240 


TUMORS  OF  THE  CRANIUM 


through  the  skin.  In  angiomas  of  very  young  children  it  is  preferable 
to  defer  operation  until  the  child  is  four  or  five  years  old,  provided 
the  tumor  does  not  grow  rapidly.  However,  should  this  happen,  opera- 
tion need  not  be  delayed.  In  very  young  children,  transfixation  and 
ligation  is  preferable  when  possible  because  of  the  lessened  danger 
of  hemorrhage.  Bryant  has  used  injections  of  boiling  water  success- 
fully. Babes  recommends  surrounding  the  tumor  with  a  chain  stitch, 
the  sutures  passing  deep  enough  to  include  all  the  vessels.  The  tumor 
is  then  excised  and  the  wound  accurately  sutured,  after  which  the 
hemostatic  sutures  are  removed.  Acupuncture  needles  have  been  used 
for  this  purpose. 

Fig.  I. 


Cirsoid  aneurysm  of  the  scalp. 


In  cirsoid  aneurysms  ligation  of  as  many  vessels  as  possible  at  a  safe 
distance  from  the  tumor  is  often  curative;  and  in  other  cases  excision 
may  be  made  possible  by  this  preliminary  step. 

Bryant  has  employed  a  method  in  aneurysms  on  the  forehead  that 
has  much  to  commend  it.  The  shaved  head  is  incised  from  ear  to  ear, 
as  in  postmortem  section.  The  anterior  portion  of  the  scalp  is  then 
deflected  over  the  face,  and  as  many  vessels  as  possible  are  ligated  from 
the  under  side.  Rubber  tissue  is  placed  over  the  vault  of  the  cranium 
and  the  scalp  replaced  over  it.  In  a  few  days  it  is  again  deflected  and 
the   tumor  dissected   from   the   under  side  of  the   skin.     This   permits 


C.IkClXOMJ 


241 


the   rciii()\al  of  the   tiinior  wirlioiir   the   pei  {omtioii   of    the  skin   and   a 
scar  is  thus  a\'<)ulecl. 

Carcinoma.  L'aieinonias  aie  nuieh  less  eotiinion  in  the  hair\'  scalp 
than  on  the  face.  In  <')75  epitheliomas  obser\eci  in  w  Herrmann's 
clinic,  on!)'  36,  or  5.3  per  cent.,  were  on  the  scalp.  1  hese  j^row  ths  may 
in  general  be  di\iclecl  into  two  groups:  (l)  Ihose  arising  from  \sarts, 
which  are  ver\  liable  to  undergo  retrograde  changes  and  give  rise  to 
fungiform    ulcerated    masses;    these   occur   particularly    in    the   occipital 

l-ic.  149 


Superficial  epithelioma  of  the  scalp. 

region.  (2)  The  flat  ulcerating  type  (Fig.  149),  which  arise  from  pre- 
existent  lesions,  such  as  tuberculous  scars  and  old  seborrheic  patches, 
and  form  superficial  spreading  ulcers.  Both  groups  have  the  hard 
infiltrating  border,  characteristic  of  carcinoma,  with  the  small  white 
comedo-like  plugs.  These,  like  the  epitheliomas  of  the  face,  frequenth' 
e.xist  for  many  years  without  involving  the  underlying  tissues  or  form- 
ing metastases.  Both  tA'pes  tend  to  grow  into  the  bone,  sometimes 
even  involving  the  dura  and  the  brain  substance  itself.  Rareh-  metas- 
tatic carcinomas  of  the  diploe  have  been  observed. 
16 


242  TUMORS  OF  THE  CRANIUM 

Diagnosis. — The  ulcerative  type  must  be  differentiated  from  syphilitic 
and  tuberculous  ulcerations.  From  the  former  they  may  be  distin- 
guished by  their  slow  growth,  by  the  fact  that  they  are  usually  solitary, 
and  by  their  infiltrating  borders  with  cancer  plugs.  They  are  not 
influenced  by  treatment  with  potassium  iodide.  From  tuberculous 
ulceration  they  may  be  distinguished  by  their  more  deepl}^  infiltrated 
border  and  by  the  presence  of  cancer  plugs.  In  rare  instances  micro- 
scopic examination  of  an  excised  piece  is  necessary  for  positive  diagnosis. 
The  nodular  type  must  be  differentiated  from  sarcoma  and  endothe- 
lioma. From  the  former  they  may  be  distinguished  by  the  increased 
disposition  to  ulcerate  and  lessened  disposition  to  early  metastasis. 
From  the  latter  by  their  much  more  rapid  growth  and  the  greater  dis- 
position to  form  metastases. 

Treatment. — If  treated  early  before  the  pericranium  is  involved  simple 
excision  of  the  soft  parts  wide  of  the  tumor  is  sufficient.  Frequently, 
however,  the  bone  is  involved  when  the  patient  is  first  seen.  In  such 
cases  the  entire  thickness  of  the  skull  should  be  removed  with  chisel 
and  rongeur,  not  the  outer  table  only,  as  formerly  recommended.  In 
cases  where  the  dura  and  even  the  brain  are  involved,  wide  excision 
has  been  followed  by  relief  for  a  considerable  time.^  Osteoplastic  cover- 
ing of  the  cranial  defects  so  made  need  not  be  undertaken.  The  cervical 
lymph  glands  should  be  removed  at  the  primary  operation.  This  has 
generally  been  omitted  in  the  past,  and  some  operators  still  omit  it. 
After  metastasis  has  taken  place,  however,  there  can  be  no  difference 
of  opinion;  they  must  be  completely  removed.  When  lymphatic  metas- 
tasis is  present  the  case  was  formerly  regarded  as  hopeless,  but  with 
the  modern  method  of  block  dissection,  further  effort  is  justified. 

Endotheliomas  (Fig.  150). — These  tumors  occur  as  slow  growing, 
papillary,  nodular,  or  ulcerated  masses.  When  small  they  may  be 
slightly  constricted  at  the  base  and  covered  with  epidermis  somewhat 
thinner  than  normal.  As  they  increase  in  size  they  tend  to  become 
nodular,  and  when  they  have  attained  the  size  of  a  split  walnut  they 
usually  ulcerate.  They  tend  to  heal,  only  to  break  down  again.  As 
the  tumor  increases  in  size  the  ulcerative  process  becomes  more  general 
until  the  entire  surface  is  affected.  The  growth  acquires  an  irregular 
granular  base  and  an  elevated,  undulating,  slightly  constricted  border. 
The  color  is  redder  than  the  surrounding  skin  and  is  mottled  with  dark 
blue  patches.  The  normal  skin  forms  a  wall  about  the  base  of  the  tumor 
and  terminates  at  the  edge  of  the  ulcer  in  a  thin,  sharply  defined  margin 
of  epidermis  resembling  very  much  the  division  of  normal  skin  from  the 
vascular  area  in  a  spina  bifida. 

^  Braun,  Verhandl.  d.  deutsch.  Gesellsch.  f.  Chir.,  1892,  xxi,  439. 


EMXJTIU.I.KJM.IS 


24  :i 


I  lie  tumors   are  slow  of  growth,  and  usiiall\-  years  elapse  before  tiie 
ulcerative    staj^e    is    reaelu-d.      Seeoiulary    nodules   occasionalh'    form    in 

Fig.  150 


Endothelioma  of  the  scalp. 


c 


fj 


■;>-:c>^ 


^■ 


r—j^-:o 


Benign  qstic  epithelioma:    a,  epidermis;  b,  tumor  mass;  c,  cysts  within  the  tumor. 


244  TUMORS  OF  THE  CRANIUM 

the  region  of  the  primary  tumor,  but  there  is  httle  tendency  to  the 
formation  of  metastases.  However,  endotheliomas  have  been  known 
to  undergo  sudden  exacerbations  in  growth,  accompanied  by  rapid 
invasion  of  the  surrounding  tissue  and  the  formation  of  metastases. 
Tumors  identical  with  these  in  external  form  and  clinical  course  are 
sometimes  formed  of  cystic  epithelial  spaces  (Fig.  151).  Others,  again, 
approach  a  sarcomatous  structure. 

Diagnosis. — Their  slow  growth  and  their  ulcerated,  thinned  epidermal 
covering  are  usually  sufficient  to  distinguish  them.  The  ulceration 
lacks  the  dirty  incrustation  of  epithelioma,  and  the  firm  constricted 
base  differs  markedly  from  carcinoma,  which  is  more  fungoid,  dense, 
and  fades  gradually  into  the  surrounding  tissue.  Tuberculous  processes 
are  less  elevated  and  the  outlines  are  less  regular.  Syphilis  and  sarcoma 
are  more  rapid  processes.  On  cross-section  the  structure  resembles 
carcinoma  very  closely,  and  careful  microscopic  study  is  sometimes 
required  to  differentiate  them.  Their  clinical  features  furnish  a  safer 
guide  to  diagnosis  than  does  the  gross  inspection  of  the  cut  surface. 
This  latter  point  should  be  remembered,  for  no  doubt  many  of  these 
tumors  are  classed  as  carcinoma. 

Treatment. — Simple  excision  results  in  a  cure.  If  sufficient  tissue 
is  not  removed  local  recurrence  may  take  place,  but  persistence  in  the 
removal  of  the  local  recurrences  will  result  in  a  permanent  cure.  When 
the  period  of  rapid  growth  has  been  reached  the  prognosis  is  much  less 
favorable,  and  even  wide  excision  is  usually  followed  by  rapid  recur- 
rence and  metastases. 

Sarcoma. — Sarcomas  of  the  cranium  may  be  divided  into  two  groups 
— those  beginning  in  the  soft  parts,  and  those  originating  in  the  skull 
proper. 

Sarcoma  of  the  soft  parts  may  be  derived  from  the  skin,  from  the 
fascia,  or  from  scars.  Those  from  the  skin  frequently  develop  from 
pigmented  moles  which  have  lain  dormant,  and  which  because  of  some 
irritation  begin  to  proliferate.  They  often  form  early  lymphatic  and 
visceral  metastases.  The  papillary  tumors  described  by  older  writers 
as  sarcomas,  and  as  characterized  by  slow  growth  and  tendency  to 
recur,  I  have  found  to  correspond  to  the  endotheliomas  as  described 
by  Mulert.^  The  fascial  sarcomas  form  lobulated,  bosselated  tumors, 
which  rapidly  invade  the  surrounding  parts  and  tend  to  form  visceral 
metastases,  but  in  a  less  degree  than  the  pigmented  type.  Their  growth 
is  frequently  so  rapid  and  the  invasion  so  extensive  that  the  exact  point 
of  origin  is  difficult  to  determine. 

The  sarcomas  of  the  cranium  may  go  out  from  either  surface,  peri- 

1  Arch.  f.  klin.  Chir.,  1897,  liv,  658. 


syr/ii/.is  -M.) 

osteal  (»i  (.lural,  oi  iVom  tin-  iliplor  in\  iloj^fnic).  Vhty  usiiall)'  torni 
ht-rnisplurical  masses,  winch  may  appear  on  rlu-  siirtace  ot  the  skull 
or  ma\'  project  into  the  cranial  cavity  and  manifest  themselves  b\' 
svmptoms  of  hiain  pressure.  I  In-  location  of  these  tumors  is  usuall\' 
on  tin-  lateral  pait  of  the  skull  oi  ahout  the  mastoid  process.  Ot  the 
timiors  arising  in  the  diploe,  Neufeld  made  the  observation  that  the\' 
extend  as  far  into  the  cranial  cavit\-  as  the\'  project  outside  the  surface 
of  the  skull.  .Accordinii  to  I  lei/in<!;er,  sarcomas  growing  from  the  dura 
tend  to  grow  upward,  and  those  growing  from  the  base  of  the  skull 
show  a  disposition  to  grow  into  the  brain. 

Treatment. — In  sarcomas  of  the  cranium,  surgical  treatment  is  seldom 
possible  because  of  their  rapid  growth.  This  is  particularly  true  of 
those  beginning  in  the  soft  parts.  Thex'  have  usuall\-  already  made 
such  deep  inroads  when  first  observed  that  cure  is  out  of  the  question. 
Some  of  the  slower  growing  t\pes,  particularly  those  of  mA'elogenous 
origin,  ofter  legitimate  objects  for  operation,  with  a  fair  prognosis,  even 
when  the  dura  is  already  involved.  Simple  free  excision  is  usually 
sufficient  since  metastases  are  rare. 

Weisswange^  collected  88  cases,  of  which  29  were  subjected  to  radical 
operation,  with  13  recoveries;  6  of  these  were  known  to  be  free  from 
recurrence  after  from  tw^o  to  six  years.  Of  these  88  cases,  40  w  ere  m\elo- 
genous,  23  w^ere  periosteal,  and  29  were  dural,  while  in  5  cases  the 
point  of  origin  could  not  be  determined.  In  the  past  sarcomas  have 
not  been  diflPerentiated  from  endotheliomas,  and  the  inclusion  of  the 
latter  in  statistics  probably  accounts  for  some  of  the  favorable  results 
in  those  situated  in  the  soft  parts. 

Syphilis  (Fig.  152). — Syphilis  of  the  cranium  ma}'  be  of  congenital 
origin,  but  is  usually  a  late  manifestation  of  the  acquired  disease. 
Syphilitic  periostitis  or  gumma  of  the  diploe,  or  simultaneous  affections 
of  the  bones  and  soft  parts,  with  the  resulting  ulcerations,  ma\-  be 
mistaken  for  neoplasms.  The  gummatous  processes  withm  the  diploe 
or  the  periosteal  inflammation  may  form  hemispherical  tumors.  Those 
which  arise  quickly  are  tender,  but  those  which  develop  more  slowly 
ma\-  be  but  slightl\-  painful.  They  are  frequentl\-  multiple  and  are  rapid 
in  onset,  usualh'  forming  in  a  few  weeks  or  months.  When  ulceration 
occurs,  either  from  the  breaking  down  of  gumma  of  the  soft  parts  or 
from  the  extension  of  a  periostitis,  the  picture  is  that  of  an  ulcer  extend- 
ing to  the  bone  or  involving  it.  Like  s\philitic  ulcers  elsewhere,  they 
are  reniform;  the  edges  are  undermined  but  not  inhltrated.  They 
are  located  usualh-  in  the  anterior  portion  of  the  scalp  and  forehead 
(Wallett). 

^  Inaug.  Diss.,  liibingen,  1897. 


246 


TUMORS  OF  THE  CRANIUM 


Diagnosis. — Before  ulceration,  syphiloma  must  be  differentiated  from 
sarcoma.  Rapid  growth,  painfulness,  and  multiplicity  suggest  the 
specific  disorder.  When  occurring  in  the  diploe  the  therapeutic  test 
is  the  most  trustworth}^  means  of  differentiation.  Their  oval  or  kidney 
shape,  their  grouping,  and  their  multiplicity  should  distinguish  them 
from  tuberculosis.  Their  multiplicity,  rapidity  of  development,  and  the 
character  of  their  edges,  together  with  the  therapeutic  test,  which  should 
never  be  omitted  in  case  of  doubt,  differentiate  them  from  carcinoma. 
It  should  not  be  forgotten,  however,  that  carcinoma  may  be  implanted 

Fig.  152 


Syphilis  of  the  scalp:     a,  gummatous  areas. 

upon  either  a  tuberculous  or  a  syphilitic  process.  In  doubtful  cases 
the  therapeutic  test  should  always  be  tried,  though  it  must  be  remem- 
bered that  the  gummas  which  are  undergoing  softening  when  the  thera- 
peutic test  is  commenced  may  continue  to  enlarge,  notwithstanding 
the  administration  of  potassium  iodide.  Evidence  of  syphilis  elsewhere 
is  of  importance,  history  of  the  disease  much  less  so.  The  Wassermann 
reaction  may  be  applied  as  a  confirmatory  test. 

Treatment. — The  treatment  is  that  ordinarily  indicated  in  tertiary 
syphilis.  In  the  early  gummatous  or  periosteal  type,  constitutional 
antiluetic   treatment   is    sufficient.      Gummas  which   are   softening  but 


Mi/r.isr.iric  ri  M'jrs  m   rin:  ski  i.i.  i.M7 

have  not  yet  ulct-ratccl  iiia\'  In-  trcatctl  l)\  iiuision  and  cuitttaKe.  I  luy 
should  tht-n  In-  packed  with  jiau/i-  irnpr(K>i:ifid  with  int  rcurial  oinrnuiu 
and  dressfd  with  on  i  i  lap|Mn<!,  hi\cis  of  adh(si\c  phistc-r,  drawn  siiHi- 
(.•i<.iul\  ti^ht  to  nKik(  iucssluc.  I'lcci  ations,  ofconrse,  are  treated  in  the 
sanu-  \\a\  .       I "hf  suhsiipient  treatnuiu  is  that  of  tertiar\'  s\phihs. 

Osteomas.  Tlu'  l^ony  rumors  ol'  ilu-  cranium  usuall\-  ajipcar  as 
(.hurnated  hemispherical  excrescences  in  the  frontal  and  tempoial  le^ions. 
The)'  are  slow  grovvinj^  and  painless.  They  do  not  extend  into  the  cranial 
cavitw  Tumor-like,  localized  hyperplasias  of  hone  extending  mto  the 
skull  ar  the  ossif\  in<i;  centres  ma.\-  occur  (Schiller).  Osteomas  grow- 
ing  our  from  the  diploe  or  from  the  frontal  sinuses  are  irregular  in  out- 
line and  cancellated  in  structure.  They  are  likely  to  be  associated  with 
similar  structures  within  the  cranial  cavity  (see  Tumors  of  the  Orbit j. 
Diagnosis. — They  ma\-  be  mistaken  for  beginning  sarcoma  and  for 
s\philitic  processes.  Their  very  slow  growth  is  sufficient  to  distinguish 
the  hard  type,  but  in  the  cancellated  type  careful  microscopic  examina- 
tion ma\-  be  necessar\'  for  differentiation.  They  are  sometimes  traumatic 
in  origin,  though,  as  v.  Bergmann  remarks,  a  traumatic  etiology  is  more 
often  assumed  than  proved. 

Treatment. — The  typical  osteomas  are  innocent  growths,  and  ordi- 
narily- do  not  require  removal  except  for  cosmetic  effect.  This  ma}' 
be  easily  done  with  a  chisel.  However,  symptoms  due  to  pressure  on 
surrounding  structures  may  demand  rehef  in  the  larger  ones  which 
spring  from  the  sinuses.  These  sometimes  require  extensive  opera- 
tions, which  are  Hkely  to  be  attended  by  great  hemorrhage. 

Metastatic  Tumors  of  the  Skull. — The  cranial  bones  are  occasionally 
the  seat  of  tumors  transplanted  from  distant  sites.  Carcinomas  are 
most  frequently  observed;  hypernephromas  or  thyroid  tumors  are 
not  infrequently  observed,  as  are  also  sync3'tiomas.  These  tumors 
manifest  themselves  as  local  thickening  of  the  skull,  differing  in  no 
wise  in  their  local  manifestations  from  primary  tumors  in  this  situa- 
tion. When  tumors  known  to  possess  a  predilection  for  metastasis  in 
this  region  are  known  to  exist,  the  diagnosis  is  at  once  highly  probable. 
Frequently  the  presence  of  the  primary  tumor  is  unsuspected;  particu- 
larly is  this  true  with  hypernephromas.  It  becomes  necessary,  there- 
fore, in  doubtful  tumors  in  the  cranium,  to  inquire  as  to  the  presence 
of  tumors  elsewhere.  In  a  number  of  instances  the  diagnosis  has  not 
been  made  until  after  the  operative  removal.  The  presence  of  hyper- 
nephroma or  thyroid  tumor  naturally  proves  it  to  be  of  secondary- 
nature.  When  tumors  are  known  to  be  secondary  in  origin,  operative 
treatment  is  of  little  avail,  though  removal  of  h\-pernephroma  or  th3-roid 
tumors  might  give  temporary  relief  if  the  primar}-  tumor  is  not  yet 
manifesting  a  rapid  growth. 


248  TUMORS  OF  THE  CRANIUM 

Pneumatocele. — By  pneumatocele  is  meant  a  tumor  produced  by  an 
accumulation  of  air  between  the  skull  and  the  pericranium,  originating 
either  in  the  frontal  or  the  mastoid  cells.  Of  the  34  cases  reported, 
24  were  mastoidal,  and  10  were  frontal. 

The  accumulation  of  air  may  be  due  to  previous  disease,  to  trauma- 
tism, or  especially  to  a  congenital  defect  in  the  bony  wall.  Nearly 
one-half  the  above  cases  fi6)  occurred  without  any  known  preceding 
disease  or  accident.  Because  of  the  etiological  relationship  between 
these  tumors  and  the  sinuses  of  the  mastoid  and  nose,  they  cannot 
occur  until  adult  life.  Several  have  occurred  during  strenuous  bodily 
efforts.  They  begin  as  small  tumors  over  the  frontal  or  mastoid  cells, 
and  sometimes,  during  formation,  the  patient  hears  the  rushing  of 
gases  into  them.  The  tumor  is  painless  and  is  covered  with  normal 
skin;  it  is  irregular  in  outline,  because  it  is  limited  by  the  attachment 
of  the  pericranium;  and  is  smooth,  elastic,  and  fluctuating.  At  the 
point  where  the  pericranium  is  lifted  from  the  skull,  bone  production 
takes  place  and  a  bony  ridge  may  afterward  appear.  The  tumor  dis- 
appears under  pressure,  and  on  the  removal  of  the  pressure  returns 
to  its  former  size,  an  occurrence  which  may  be  expedited  by  inflating 
the  ear.  The  patient  is  able  to  feel  the  entrance  and  exit  of  the  air 
during  this  process.    The  percussion  note  is  tympanitic. 

Diagnosis. — Difi^erentiation  must  be  made  from  emphysema  of  the 
scalp,  a  condition  in  which  the  tumor  is  not  sharply  circumscribed 
on  account  of  the  air  being  in  the  cellular  spaces.  A  pneumatocele 
does  not  crackle  on  palpation.  While  compressible,  emphysema  can- 
not be  uniformly  reduced,  nor  is  it  attended  by  the  sense  of  rushing 
air.  Fluid  under  the  pericranium  may  simulate  it,  but  the  diff^erence  in 
the  percussion  note  is  distinctive.  The  diagnosis  is  so  self-evident  that 
it  would  seem  that  there  can  be  no  excuse  for  a  mistaken  diagnosis 
if  the  possibility  of  the  condition  is  kept  in  mind. 

Treatment. — The  treatment  applied  in  McArthur's  case^  was  free 
incision  with  a  counteropening  and  packing  with  iodoform  gauze  after 
chiselling  away  the  exostosis  formed  about  the  border.  Cure  resulted 
in  about  three  weeks.  Aspiration  with  injection  of  irritating  fluids 
would  now  seem  superfluous  with  our  aseptic  technique.  Sonnenburg 
successfully  covered  an  opening  in  the  mastoid  with  a  bone  flap. 

Sinus  Pericranii.- — By  this  term  is  understood  a  rare  condition  in 
which  cysts  containing  circulating  blood  are  formed  under  the  perios- 
teum. They  are  in  open  connection  with  the  sinus  longitudinalis  through 
large  emissary  veins.     They  are  always  traumatic  in  origin.     They  are 

^  Jour.  Amer.  Med.  Assoc,  1905,  xliv,  1418. 
^  Stromeyer,  Deutsch.  Klin.,  1850,  p.  160. 


CKRKHR.IL  HI.  KM, I  24'J 

usuall\'  located  in  the  median  line,  are  globular  in  form,  usually  not 
larfj;er  than  a  walnut  and  are  soft  or  elastic  and  su^^est  fluctuation. 
1  he\  may  he  pressed  into  the  skull  throujih  an  openinj^  which  after- 
ward may  possibly  he  palpated.  A  famt  pulsation  may  be  nt^ted. 
The  tension  of  the  wall  mcreases  with  an  increased  intracranial  press- 
ure.' The  surface  is  coxered  with  normal  <^r  attenuated  skin,  and  it 
may  be  bluish  red  from  the  dilated  veins.  Both  Cushing's  cases  were 
associated  with  slowly  growing  brain  tumors.  In  one  of  them  dilated 
vessels  radiated  from  the  tumor  to  the  frontal  and  occipital  regions. 
In  both  cases  the  tumor  disappeared  after  the  circulation  had  been 
readjusted  by  decompression  operations. 

Diagnosis. — These  tumors  must  be  distinguished  from  meningoceles 
and  cephiilhydroceles. 

Treatment. — Compression  has  proved  to  be  useless.  If  rupture  threat- 
ens, iodoform  tamponage  ma\'  be  required.  An  osteoplastic  closure 
of  the  opening  might  be  considered    v.  Bergmann). 

Meningocele  Spuria  ( Billroth  i,  Cephalhydrocele  Traumatica  (v. 
Bergmann). — These  tumors  result  from  subcutaneous  skull  fractures 
occurring  at  birth  or  during  childhood,  from  which  cavities  filled  with 
fluid  develop.  They  are  usually  elongated,  corresponding  to  the  shape 
of  the  fracture,  but  they  ma\'  be  oval.  The  bone  does  not  heal  over 
and  the  c\sts  have  a  connection  more  or  less  deep  in  the  skull.  1  he\' 
appear  onh*  in  children,  but  may  persist  through  lite.  The  tumor  is 
fluctuating,  often  pulsating.  The  dura  is  detective  and  the  cysts  may 
extend  deep  into  the  brain  and  communicate  with  a  cephalic  cavity 
or  even  with  the  lateral  ventricle.  When  compressed  they  give  rise 
to  svmptoms  of  brain  pressure,  and  they  become  tense  when  the  intra- 
cranial pressure  is  increased.  The  opening  in  the  bone  may  be  palpated. 
The\'  are  commonly  situated  over  the  parietal  or  frontal  regions. 

Diagnosis. — They  are  distinguished  from  sinus  pericranii  by  their 
location  elsewhere  than  over  the  longitudinal  sinus,  by  the  production 
of  hypertension  phenomena  on  compression  and  finally  by  puncture  in 
obscure  cases.  Their  location  at  points  other  than  at  the  fontanelles 
distinguishes  them  from  cerebral  hernia. 

Treatment. — They  usually  persist  throughout  life,  but  since  no  symp- 
toms are  produced,  no  treatment  need  be  attempted. 

Cerebral  Hernia. — Protrusion  of  a  part  of  the  brain  or  of  the  meninges, 
or  of  both,  simulates  or  may  be  associated  with  true  tumors.  It  occurs 
at  the  occiput  (Fig.  15s)  or  sinciput,  more  frequently  at  the  former  site. 
Two  types  of  occipital  hernia  are  recognized,  a  superior  which  occurs 
in  the  region  of  the  posterior  fontanelle  and  an  inferior  which  occurs 

'  Gushing,  Keen's  Surgery,  Saunders,  Philadelphia,  1908,  vol.  iii. 


250 


TUMORS  OF   THE   CRANIUM 


about  the  foramen  magnum  and  is  frequently  continuous  with  similar 
defects  in  the  cervical  cord.  Hernias  at  the  sinciput  occur  through  a 
defect  in  the  ethmoidal  plate.  They  are  of  three  types — nasofrontal, 
naso-orbital,  and  naso-ethmoidal. 

Diagnosis. — These  tumors  are  usually  smooth  and  soft,  but  may  be 
irregular  and  quite  dense.  By  pressure  evidence  of  increased  brain 
tension  may  be  produced.  Usually,  their  congenital  origin,  their  loca- 
tion, and  their  frequent  association  with  hydrocephalus  is  sufficient 
on  which  to  base  a  diagnosis.     When  small  they  may  be  mistaken  for 

Fig.  153 


Cerebral  hernia. 


Other  tumors,  especially  dermoids.  Those  located  about  the  root  of 
the  nose  offer  most  difficulty,  particularly  because  dermoids  in  this 
situation  frequently  have  a  pulsation  transmitted  from  the  brain. 
Dermoids  are  not  compressible,  however,  and  are  more  dense  than 
cerebral  hernias.  Angiomas  in  the  same  region  are  compressible  but 
they  do  not  have  a  pulsation.  The  history  and  the  location  will  usually 
distinguish  them  from  acquired  hernia.  From  sinus  pericranii,  hernias 
are  distinguished  by  the  history  and  with  certaint}'  by  puncture.  When 
combined  with  other  tumors,  lipoma,  and  particularly  angioma,  they 
may  be  entirely  overlooked.     Tumors  in  the  region  of  the  occiput  or 


CKREIiR  II.   Ill: R M.I  LV)! 

of  tlu-   .siiuipiil    tl.itmi;   lioin    bull)    sluuild    ;il\\;i\s   l)i-   i  i}i;i  i  (led    \Mth   sus- 
picion, ;iiul  opii  ;it  ion  pioitcdnl  with  \(i\    riiiii  ioiisl\  . 

Treatment.  I'sumIK  tluic  ;irc  (.o-ixist m^  (k-toiiniiics  wincli  itiidi-r 
tii-;itnu'nt  un;i\  ailinLi,,  oi  ilu  luiin;is  ;iic  so  l;iiji;e  as  to  ni:ikc  iiciirnicnr 
Mupossddt-. 

W  lien  ni'itluT  of  tlusc  c-ontlitions  p!"c\':iil,  li^:inon  ot  rlic  s;ic  niay 
hi'  undfi  taktii. 


CHAPTER    XXI 

TUMORS  OF  THE   BRAIN  AND  SPINAL  CORD 

TUMORS   OF   THE   BRAIN 

General  Conception. — All  the  tumors  which  occur  within  the  cranial 
cavity  are,  because  of  their  cHnical  similarity,  included  under  the  caption 
Tumors  of  the  Brain,  although  the  vast  majority  are  not  of  the  brain 
itself,  and  many  are  not  true  tumors.  In  other  words,  the  exact  science 
of  oncology  must  here  more  than  anywhere  else  yield  to  practical  con- 
venience. No  writer  upon  the  subject  has  hesitated  to  discuss  under 
this  head  the  granulomas,  exostoses  of  the  skull,  and  the  various  cysts, 
proliferative,  retention,  degenerative,  and  parasitic. 

In  every  case  the  presence  of  an  intracranial  tumor  must  be  deter- 
mined first,  then  its  situation  becomes  the  paramount  problem,  and 
finally  it  must  be  identified,  pathologically.  The  knowledge  of  the 
location  of  a  tumor  serves  only  to  indicate  in  part  whether  it  is  oper- 
able or  not;  the  exact  nature  of  the  tumor  is  of  the  utmost  importance 
in  deciding  upon  the  treatment  and  in  prognosis.  In  some  cases  the 
pathology  of  the  growth  can  be  surmised  from  the  fact  that  certain 
tumors  have  a  predilection  for  certain  regions  during  certain  periods 
of  life,  but  its  nature  can  be  accurately  determined  only  during  the 
operation. 

Owing  to  recent  advances  in  the  treatment  of  brain  tumors  very 
few  are  beyond  surgical  aid,  although  very  often  palliative  measures 
only  are  possible.  The  fate  of  the  patient,  however,  depends  here 
more  than  anywhere  else  in  the  surgery  of  tumors  upon  the  knowledge 
of  living  pathology  possessed  by  the  operator. 

General  Symptoms. — All  brain  tumors  present  in  common  certain 
general  symptoms,  most  of  which  are  referable  to  increased  intra- 
cranial pressure,  though  some  may  have  a  slight  value  in  localizing 
the  disturbance. 

Headache. — The  headache  is  often  severe,  and  is  usually  felt  over 
the  entire  head,  though  it  is  frequently  more  intense  in  the  back  part. 
Sometimes  it  is  persistently  more  severe  at  one  point,  and  is  then  of 
some  value  in  localization.  It  is  increased  by  anything  that  raises  intra- 
cranial pressure,  and  is  apt  to  be  most  severe  in  the  morning,  owing 
to  the  recumbent  position  during  the  night. 


TL  M(JRS  (J J    rill:    liK.IIS  253 

Vomiting.  Xhv  Nomitiiij:;  chaiactc-nstic  ot  brain  tumor  is  projectile, 
conns  on  at  iiniiulai  inrciNals,  irrespective  ot  meals,  and  is  witli(jut 
nausea. 

Choked  Disk.  The  |Hiiplui\  of  rlu-  optic  disk  becomes  hyperemic 
and  edematous,  which  causes  a  diminution  ot  the  acuteness  of  vision 
in   tile  centre  of  the  Held  and  a  certain  decree  of  peripheral  limitation. 

Convulsions. — General  con\ulsions  are  sometimes  an  early  si^n  ot 
brain  tumor.  This  is  particularly^  suggestive  if  the  tirst  spasm  comes 
on  r(.lati\cl\    late  in  life,  /.  t\,  between  the  twentieth  and  fortieth  years. 

Mental  Aberration. — Mental  disturbance  is  sometimes  a  symptom  of 
brain  tumor.  It  is  of  little  \alue  alone,  but  is  of  importance  when  it 
occurs  with  some  of  the  more  definite  signs  of  brain  tumor. 

Focal  Symptoms. —  fhe  general  diagnosis  of  a  cerebral  tumor  is  often 
aided  b\  s\  niptoms  referable  to  the  focus  of  disturbance,  so  that  its 
recognition  and  its  location  are  often  arrived  at  simultaneousl\'.  The 
interpretation  of  such  s\mptoms  requires  a  careful  study  of  the  various 
regions  of  the  brain. 

Motor  Region.  -The  motor  region  was  the  first  to  be  analyzed,  and 
for  a  long  time  was  the  only  one  from  which  the  removal  of  a  tumor 
was  attempted.  The  first  sign  of  a  tumor  is  usuall}'  motor  irritation 
or  spasm.  This  is  particularly  well  marked  when  the  hand  area  is 
diseased.  In  such  cases  individual  muscles  are  often  affected  so  that 
a  verv  exact  localization  is  possible.  Irritation  of  a  muscle  group 
followed  by  paralysis  is  particularl}'  characteristic. 

Cerebellar  Region.^ — The  chief  evidences  of  cerebellar  involvement  are 
disturbance  of  gait  and  vertigo.  There  are  numerous  minor  symptoms 
which  may  be  considered  in  order. 

Cerebellar  Ataxia. — The  large  muscles  of  the  trunk  and  legs  are  chiefly 
involved,  so  that  standing  and  walking  are  disturbed,  while  the  finer 
movements  are  not  affected.  The  ataxia  is  usually  manifest  by  the 
disposition  of  the  patient  to  fall  toward  the  diseased  side  or  when 
walking  to  describe  a  circle  the  centre  of  which  is  on  the  diseased  side. 

P^ertigo. — This  symptom  usually  begins  earlw  It  is  not  affected  by 
closing  the  eves.  It  may  be  objective,  when  the  patient's  surround- 
ings appear  to  move  toward  the  unaffected  side;  or  subjective,  when 
the  patient  feels  as  if  he  were  falling  toward  the  unaffected  side. 

Xystagmus. — This  symptom  is  observed  usually  upon  lateral  move- 
ment of  the  e^'es,  and  is  most  marked  when  the  patient  looks  toward 
the  diseased  side. 

Other  Regions  and  Minor  Symptoms. — To  these  chief  signs  may  be 
added   several  which   give  further  evidence  as  to  location.      The  most 

*  Henschen,  Leber  Geschwiilste  der  liinteren  Schadelgrube,  Fischer,  Jena,  1910. 


254 


TUMORS  OF  THE  BRAIN  AND  SPINAL  CORD 


constant  of  these  is  adiadokokinesis,  by  which  term  is  meant  the 
inability  to  effect  rapid  coordinated  movements.  This  is  found  on 
the  diseased  side  only.  A  spinal  ataxia  on  the  affected  side  is  some- 
times noted.  The  involvement  of  the  cranial  nerves  gives  evidence 
of  the  location  of  the  lesion  either  at  their  centre  of  origin  or  at  some 
portion  of  their  course.  Frequently,  the  presence  of  a  tumor  can  be 
diagnosticated,  but  none  of  the  foregoing  evidence  of  localization  can 
be  found.  In  these  cases  some  of  the  more  indefinite  signs  may  be  of 
value.  Mental  aberration  speaks  for  localization  m  the  frontal  lobes. 
Persistent  local  pain  is  important,  especially  if  the  scalp  in  the  same 
region  is  tender  to  pressure  or  to  tapping,  or  if  the  hair  is  thin  at  that 
point.  Often,  too,  tumors  occurring  in  definite  centres  fail  to  give 
evidence  of  their  localization,  and  are,  therefore,   "silent." 

Fig.  154 


Glioma  of  the  corpus  callosum. 

The  hypophyseal  tumors  have  a  symptomatology  peculiarly  their 
own.  Acromegal}^,  when  it  is  present,  is  pathognomonic.  It  is  often 
associated  with  optic  atrophy  limited  to  the  nasal  half,  which,  even 
when  alone,  is  strongly  suggestive  of  the  pressure  of  a  pituitary  tumor 
upon  the  chiasm.  In  children,  instead  of  acromegaly,  there  may  be 
stunted  growth.  In  addition,  the  symptoms  common  to  brain  tumors 
in  general  may  also  be  present.  The  x-xdiys  are  highly  praised  by 
Church^  as  an  aid  to  diagnosis. 


1  Jour.  Amer.  Med.  Assoc,  1909,  liii,  97. 


TUMORS  or  Tin:  hk.iix  25.") 

Pathology.  Tin-  presence  of  a  tiimoi  li;i\iiiH  Ixcn  ritojiiii/cci  ;incl 
rlu'  (jiustion  ot  l()i;ili/:iti()n  liavin-;  hiin  dttei  iiijiuti,  the  piohkin  as 
to  tlu'  natiiic  ot  the  tiinioi  |)i(.sents  irsilf".  Soiiu-  ^eiieial  notions  nia\' 
1h'  ohtaiiuil  lioni  tlu  location  .iiul  ilu-  associated  conditions.  l-Oi-  in- 
stance, if  a  tumor  m  a  nuclclk-a«;cil  piison  is  located  at  the  base  of  the 
brum  tluic  is  a  smoiili,  ptohability  that  it  is  a  s\  philoma.  Interesting 
as  are  sjHciilations  as  to  the  nature  of  tiusc-  tuinois,  the  tea  I  determina- 
tion must  he  matle  when  tlu'  tiimoi   is  actiialh    before  the  operator. 

Fig.  15s 


Glioma  of  the  optic  thalamus:   a,  optic  chiasm;    /;,  tumor  nodules. 


Glioma. — About  one-sixth  of  brain  tumors  belong  to  this  class.  They 
are  infiltrating  tumors,  grayish  white,  often  mottled  (Figs.  154  and 
I55)j  and  are  frequently  excessively  vascular  (Fig.  156).  They  are 
often  softer  than  the  brain  substance  and  even  semifluctuating.  Hemor- 
rhage into  the  tumors  is  common  (Fig.  157).  This  accident  ma}-  pre- 
sent the  first  indication  of  a  cranial  disease  and  may  simulate  an  apoplex\- 
in  the  suddenness  with  which  the  symptoms  appear.     The  brain  areas 


256 


TUMORS  OF  THE  BRAIN  AND  SPINAL  CORD 


affected   may  seem  increased  m  size.      It  is   stated   that  the  reported 
bram  hj^pertrophies  are  really  gliomas.     They  vary  in  size  from  a  pea 

to  a  fist. 

Fig.  ik6 


Glioma  of  the  pons. 
Fig. 157 


Glioma  of  the  pons  with  hemorrhagic  cyst. 

Sarcoma. — These  tumors  go  out  usually  from  the  meninges  and  the 
skull.     Thev  may  be  more  or  less  encapsulated   (Fig.   158)   or  may  be 


riMoRs  or  rill,  lik.iix  '2.)i 

inHlrratinii.     Thf\'  may  likewise  be  metastatic.      Tluie  is  a  disposition 
to  class  all  iiKiliunant  cellular  tumors  as  malignant  gliomas,  and,  indeed, 

Vui.  158 


Sarcoma  of  the  meninges. 


Sarcoma  of  the  cerebellum. 


17 


258 


TUMORS  OF  THE  BRAIN  AND  SPINAL  CORD 
Fig.  i6o 


Endothelioma  of  the  dura. 


Fig.  i6i 


Endothelioma  of  the  pia  of  the  temporal  lobe. 


TC.MfJkS  oi    Till,   h'k  ll\  2.')<> 

in  many  cilliilar  tumors  j^lia  cells  nia\  \->v  discovered  in  some  portion 
of  the  tumor,  which  lends  weight  to  the  belief  that  the  sarcoma  cells 
are  dewloped  fiom  the  ^lia  cells.  Nevertheless,  some  of  these  tumors 
show  no  tiace  of  \i}\:i  tissue  ( 1' i^.  159),  and  tiuir  development  from 
gha  tissue  is  merely  assumption.  !  he  (juestion  could  apply  onl\'  to 
tumors  which   de\eloped    from   j;lia    tissue.     (Jther  distinctly   sarcoma- 

Vir..  161 


^^?^-^^~  "•i-'-o  •-•  -"'=■      -      'V      \   S>^<.  %.t2^(€''-'"  '^>■^-•■--.§^^■a'^- 

Endothelioma  of  meninges. 

tous  tumors  springing  from  the  meninges  at  least  cannot  have  this 
origin.  The  rate  of  growth  of  these  tumors  aside  from  their  structure 
would  seem  to  exclude  them  w-ith  certainty  from  the  endotheliomas. 
Endotheliomas.— The  usual  tumors  arising  in  the  meninges  are  endo- 
thelial in  origin.  They  are  dense  circumscribed  tumors  (Figs.  160 
and    161)    of    slow    growth.      The\'    are    usually    t3"pical    in    structure 


260 


TUMORS  OF  THE  BRAIN  AND  SPINAL  CORD 


(Fig.  162),  and   may  develop  C3^sts  in  their  interior  (Fig.  163).      Endo- 
theliomas containing  psammoma  bodies  are  not  rare  (Fig.  164). 


Fig.  163 

^■^Pl 

^^■^H 

^^^^^^■■1 

fv>^! 

^^^^^^^H 

IHii^^^^^^^^^l 

,y  '  '  ' ■ 

'^^" 

^^m  '^ 

%» 

^^H 

^B 

«f 

^^1 

'A';, 

^  ;.i 

^A  ^ 

' 

' 

^1 

^^^x 

^  * " 

4  ^H 

^m  i^^ 

^^1 

^B  7  ',^  - 

« 

at' 

^^^^^^H 

.^  /■ 

^^^^H 

^m  ■'■ 

<• 

•    i"  'A      t- 

^^^H 

^^^■k  '-'- 

'^^^        - 

'fl^^^^B 

^^^^^A^ 

"*     '  ..^ 

^^^ 

^^.^^^^^^B 

Endothelioma  of  the  temporal  lobe  with  multiple  cyst  formation. 

Fig.  164 


,'.^ 


-?  -'  <; 

5P0 


Endothelioma  of  the  dura,  containing  psammoma  bodies. 

Carcinomas. — These  occur  as  metastatic  tumors  (Fig.  165),  and  when 
there  is  evidence  of  brain  tumor  the  possibility  of  a  primary  tumor 
elsewhere  should  be  kept  in  mind. 


riMfjks  or  the  hk.iis 


2r,i 


Granulomas.  I  his  ^loiip  is  fouiul  usuall\'  at  the  base  aiul  may  be 
sii^m-sttcl  h\  tvicleiui'  ot  disease-  clscwluic.  I  uIhicuIosis  is  particu- 
lail\  siiji;<it'sri\f  in  tin-  \()iin^,  and  appears  as  nodules  in  the  nieninjies, 
while  syphihs  appears  in  hirer  hte  and  is  more  often  a  dittuse  thickening 

Fk;.  165 


Metastatic  carcinoma  of  the  cerebrum. 


of  the  meninges  (Pig.  166),  but  it  may  form  circumscribed  nodules. 
For  the  latter  the  specific  tests  now  available  are  preferable  to  the  more 
uncertain  therapeutic  tests.  Very  frequently  these  tumors  cannot 
be  diagnosticated  even  at  operation. 


262 


TUMORS  OF   THE  BRAIN  AND  SPINAL  CORD 


Cysts. — Cysts  of  the  brain  are  due  to  numerous  causes.  An  old  hemor- 
rhage may  be  converted  into  a  cyst,  in  which  case  cholesterin  crystals 
bear  evidence  of  its  origin.  Brain  abscesses  may  terminate  in  cysts, 
the  diagnosis  depending  largely  upon  history  and  location.  The  centres 
of  some  of  the  cellular  tumors,  especially  gliomas,  may  liquefy  either 
by  hemorrhage  or  by  necrosis;  the  portion  of  the  tumor  remaining 
may  be  reduced  to  a  capsule  which  requires  a  microscopic  examina- 
tion for  its  identification.     Cysts  often  appear  without  demonstrable 

Fig.  i66 


Syphilis  of  the  dura. 

cause,  as  may  be  inferred  from  the  foregoing.  Parasitic  cysts  have  been 
observed.  Cysts  of  the  ependyma  (Fig.  167),  which  are  usually  inno- 
cent in  character,  are  sometimes  observed. 

Rare  Tumors. — Lipomas  and  fibromas  have  been  reported.  It  is 
possible  that  metastatic  hypernephromas  have  been  mistaken  for 
lipomas.  Aneurysms  sometimes  give  the  general  symptoms  of  bram 
tumor.i  Teratomas  are  sometimes  observed  at  the  base,  particularly 
in  the  hypophysis. ^ 


1  Blank,  Munch,  med.  Wochenschr.,  1910,  Ivii,  465. 

2  Hecht,  Jour.  Amer.  Med.  Assoc,  1909,  liii,  looi. 


TLWKJRS  or   rill.    HR.IIS 


2(i3 


Diagnosis.  I  lu-  diji^nosis  of  increased  ini  i;ui  :iiii;il  |)i{ssiiic  is  tlie 
iiKitti'i'  ot  inmu'  im[)<)i  I  :i  iu<- ;  ;iiul,  csj'x-ci;!  Il\  wlun  iicn  iinp;)  nicd  In' 
t)pru"  luiiiitis,  IS  siirticuii  I  iinlun  I  loll  loi  cxploi  ;i  t  oi  \  opi  i;iiion.  I)i;iin 
tiiinoi  m;i\  simuhiic  \;irioiis  oilur  (.oiulii  ions.  I  he  t  oii\  nlsions  iiki\- 
leail  to  tin-  cli:i<;n()Sis  ot  e|iilcps\  ;  Init  when  epiitptoul  s\  niptoiiis  Hist 
appear  late  m  lite,  tlie\'  should  always  raise  siispuion  ot  tumor.  1  he 
visual  ehanms  toinuily  re<;ar(k-d  as  pat lio^iioinonu-  ot  hysteria  have 
been  observed  m  the  eail\'  stages  ot  hram  timioi,'  and  in  spire  ot 
ever)'  care,  embarrassin<i;  errors  arise  in  tlitteientiatin^  rlu-  two  diseases. 
Nephritis-  ma_\'  present  symptoms  which  suggest  l)rain  tumor. 

I''if;.  167 


Cyst  of  the  ependyma  discovered  post  mortem. 

Prognosis. — The  prognosis  of  brain  tumor  is  variable.  S\philomas 
often  respond  promptly  to  treatment.  Tuberculomas  ma^'  recede 
spontaneous!}'.  C}'sts  may  lie  a  long  time  dormant.  Ihe  majoritx' 
of  brain  tumors,  however,  advance  to  fatal  termination  unless  relief 
is  secured  by  operative  means.  Palliative  operations  when  done  b\' 
experienced  hands  have  a  low  mortality.  7  hose  cases  in  which  the 
tumor  can  be  removed  have  a  mortality  of  at  least  25  per  cent.  In 
inexperienced  hands  these  figures  are  probably  quadrupled. 


^Gushing,    Boston   Med.   and    Surg.   Jour.,    1909,  clxi,  71;    I'aikcr,   jour.    .Amer.  Med, 
Assoc,   1909,  liii,  91. 

-  Bramweil,  Clinical  Studies,  1905,  N.  S.,  iii,  183. 


264  TUMORS  OF  THE  BRAIN  AND  SPINAL  CORD 

Treatment. — Tuberculomas  may  be  benefited  by  general  treat- 
ment and  syphilomas  by  specific  treatment.  Tuberculomas  are  often 
circumscribed,  and  are  sometimes  primary,  in  which  instance  they  are 
suitable  objects  for  removal.^  Syphilomas  are  often  resistant  to  specific 
treatment,  in  which  case  they  may  be  treated  surgically;  but  because 
they  are  so  often  diffuse  this  is  rarely  possible. 

The  true  tumors  are  amenable  to  operative  treatment  only.  Endo- 
theliomas, because  of  their  location  in  the  meninges,  their  perfect  encap- 
sulation, and  their  slow  growth,  are  the  most  favorable  for  operation. 
Gliomas,  because  they  have  just  the  contrary  characteristics,  are  seldom 
operable.  When  a  tumor  can  be  localized,  there  is  a  possibility  of  its 
removal;  the  technique  in  each  case  must  be  suggested  by  the  experi- 
ence of  the  operator.  When  the  tumor  cannot  be  localized,  or  when  it 
is  in  an  maccessible  region,  much  may  be  done  in  the  way  of  palliation 
by  means  of  decompression.  This  consists  in  the  removal  of  a  window 
of  bone  for  the  purpose  of  permanently  increasing  the  intracranial 
space.  This  is  done  in  the  temporal  region  in  order  that  the  temporal 
fascia  may  be  employed  as  an  elastic  retaining  wall  to  prevent  a  too 
great  herniation  of  the  brain.-  A  few  spontaneous  cures  of  brain  tumors 
have  been  reported.  Hemorrhage  into  the  tumor^  with  subsequent 
absorption  seems  to  explam  some  of  these  instances.  The  results  of 
surgical  treatment  are  still  not  brilliant.  In  26  cases  reported  by 
Leischner^  only  one  patient  was  well  after  three  and  one-half  years. 
In  a  group  of  less  malignant  tumors,  Berteaux  and  Burnier^  report 
better  results.  Of  13  cerebellar  cysts,  all  but  one  recovered  after 
operation.  Of  17  cerebellar  gliomas,  5  were  cured.  Of  9  fibromas  and 
sarcomas,  only  2  recovered.  In  all,  56  cases  were  operated,  of  which 
17  recovered. 

TUMORS    OF   THE    SPINAL   CORD« 

General  Conception. — Tumors  of  the  spinal  cord  have  but  recently 
become  objects  of  practical  interest.  Schlesinger,  in  35,000  autopsies, 
reports  151  cases  in  which  tumor  was  present  in  the  spinal  column, 
spinal  meninges,  or  cord.     In  104  only  was  the  cord  affected.     Tumors 

1  Alessandri,  Ann.  Surg.,  1906,  xliii,  161. 

2  Gushing,  Surg.,  Gynec,  and  Obst.,  1905,  i,  297,  and  Keen's  Surgery,  Saunders,  Phila- 
delphia, 1908,  iii. 

^  Anton,  Miinch.  med.  Wochenschr.,  1909,  Ivi,  848. 

^  Arch.  f.  klin.  Chir.,  1909,  Ixxxix,  542.  ^  Arch.  gen.  de  Chir. ,  1509,  iii,  127. 

^Schlesinger,  Handb.  d.  path.  Anat.  des  Nervensystems,  Berlin,  1903;  R.  H.  Hart, 
Annals  of  Surgery,  1905,  xlii,  524;  R.  T.  Williams,  Diseases  .of  the  Spinal  Cord,  London, 
1908. 


riMoks  or  the  s/>/.\,/l  cord 


2(;o 


may  be  vertebral,  external  to  flu-  iiunin{i;es,  or  meningeal,  inrradural, 
and  inrraniediillary.  All  except  the  last  produce  injiir\'  In  pressure. 
1  hn  r\  |Hr  cent,  are  medullary,  40  per  cent,  nieninj^eal  but  intradural, 
and  less  than  20  pel  cent,  are  ineinn^eal  and  extradural.  1  unior.s  of 
the  vertebra,  nearl\  always  nutaslafic,  are  twice  as  common  as  all 
other  forms. 

Fic.  16S 


\\^ 


Fibrom\-xoma  of  the  dorsal  cord.     (Redrawn  from  a  sketch  b\-  the  author; 
Plummer-Grinker's  case.) 

S3miptoms. — The  intramedullary  variet}'  presents  s\mptoms  of 
a  cord  lesion,  often  those  of  syringomyelia.  The  extra-  and  intradural 
give  signs  of  cord  compression,  pain  and  sensory  disturbances,  and,  less 
constantly,  motor  disturbance.  The  pain  is  intense,  and  is  referred 
to   the    distribution  of    the   nerves   which   are   compressed;    it   is    often 


266 


TUMORS  OF  THE  BRAIN  AND  SPINAL  CORD 


constant,  and  ceases  only  with  the  destruction  of  the  nerve.  A  zone 
of  hyperesthesia  indicates  the  height  of  the  lesion. 

Extradural. — These  tumors  may  begin  from  any  tissue  of  the  spinal 
column  external  to  the  dura  or  from  the  external  surface  of  the  dura 
itself.  The  most  frequent  extradural  tumors  are,  as  above  indicated, 
metastatic  carcinomas  and  sarcomas  either  within  the  bone  or  in  the 
soft  tissues  surrounding  the  dura.  Tumors  originating  primarily  in  the 
extradural  space  are  usually  benign.  Cartilaginous  or  osseous  tumors 
are  rare;  fibromas,  myxofibromas,  and  Hpomas  are  more  common. 
Lymphoid  tumors  and  primary  malignant  tumors  have  been  noted. 

Intradural. — Tumors  which  arise  within  the  dura  and  external  to 
the  cord  are  of  the  same  varieties  as  the  primary  extradural  tumors; 
the  most  frequent  being  fibromas  or  myxofibromas  (Fig.  i68).  Other 
forms  are  more  rarely  seen.  Tuberculomas  and  gummas  are  of  relatively 
frequent  occurrence.  Neuromas  are  sometimes  observed  about  the 
nerve  roots.  Carcinoma,  whether  arising  primarily  or  by  extension, 
is  rare  in  this  situation. 

Fig.  169 


Glioma  of  the  cervical  cord. 


Intramedullary. — These  occur  usually  about  the  central  canal,  but 
occasionally  from  the  substance  of  the  cord  or  from  the  pia.  Gliomas 
(Fig.  169)  are  the  most  frequent  of  the  true  tumors.  Fibromas  and 
myxofibromas  and  sarcomas  in  various  combinations  with  connective 
tissue  occur.  Tuberculous  and  syphilitic  processes  are  likewise  found. 
Metastatic  tumors  within  the  cord  are  pathological  curiosities. 

Diagnosis. — The  presence  of  a  localized  cord  lesion  with  severe  pain, 
when  other  cord  lesions  can  be  excluded,  furnishes  the  main  point  in 
diagnosis.  The  kind  of  tumor  is  more  difficult  to  determine.  Gliomas 
often  give  signs  of  syringomyelia.  The  nature  of  the  secondary  tumors 
may  be  surmised  when  primary  tumors  are  known.  Mammary  tumors 
are  particularly  apt  to  form  vertebral  metastases. 

Treatment. — Fibromas  and  exostoses  are  capable  of  removal.  Glio- 
mas are  inoperable. 


C  II  A  1'  T  J',  k     \  X   I   I 


TUMORS  OK    rilK  ORHIT'  AM)  I.ACm'.MAI.  CI.ANDS 


Fig.  170 


I  iiiiiois  ot  tlu'  oiim  an-  oiclinanl)-  ciiNiclccl  into  th(jse  which  arise 
within  the-  oihir  and  rhosc  which  arise  without  and  invade  the  (jrbit 
secondarilw  The  chnical  manifestations  of  a  tumor,  however,  vary 
more  with  its  nature  than  with  its  point  of  origin,  and  growths  of  the 
same  kind  ma\'  arise  either  within  or  without  the  orhit.  It  seems  more 
satisfactor\',  therefore,  to  disregard  the  point  of  orgin  of  these  tumors 
and  classif)"  them  pathologically. 

Sarcoma. — Sarcomas  are  the  most  malignant  tumors  of  the  e\'e, 
and  are  especially  frequent  in  young  persons.  The\'  are  of  all  cellular 
types,  and  ma}'  develop  from  the  episcleral  tissue,  Tenon's  capsule, 
and  the  periosteum  of  the  orbit.  Higher  types  of 
sarcoma  have  been  reported,  such  as  chondrosar- 
coma, myxosarcoma,  and  frequently  fibrosarcoma. 
The  disposition  of  some  authors  to  classify  tumors 
of  the  last-named  group  as  endotheliomas  is 
warranted  both  from  their  structure  and  their 
clinical  course.  Melanotic  sarcomas  are  some- 
times primary  (Fig.  170)  in  the  orbit,  arising 
independent  of  pigment-bearing  areas.  The  more 
common  type  is  the  melanotic  gliosarcoma  which 
begins  in  the  pigmented  cells  of  the  retina,  where 
It  can  be  seen  with  the  ophthalmoscope  as  a  nodule 
bulging  into  the  cavit)'.  Later,  the  pigmented 
mass  presents  itself  m  the  anterior  chamber  and 
may  perforate  the  cornea.  More  often  it  first 
perforates   the   eyeball    farther   back   and   fills  the 

orbit  (Fig.  171).  The  entire  e3'eball  may  be  destroyed,  and  the  orbit 
then  presents  a  pigmented  ulcerating  surface  (Fig.  172).  The  opposite 
eye  may  later  become  affected.  Instead  of  destroying  the  e\eball, 
extension  ma}'  take  place  in  other  directions,  notabl}"  into  the  tissue  of 
the  temple  (Fig.  173). 

Lymphosarcoma. — These  tumors  are  sometimes  reported.  They 
develop  usuall}'  in  the  region  of  the  lacrymal  gland,  and  are  not  infre- 
quently symmetrical. 


Melanoma  in  the  or- 
bital fatty  tissue  above 
the  eve. 


^  For  the  literature  of  tumors  of  the  orbit   see  J.  H.  Parsons,  The  Pathology  of  the 
Eye,  Putnam,  New  York,  1905,  and  Lagrange,  Tumeurs  de  I'Orbite,  Steinheil,  Paris,  1904. 


268  TUMORS  OF  THE  ORBIT  AND  LACRYMAL  GLANDS 

Fig.  171 


Gliosarcoma  of  the  eyeball,  which  has  perforated  the  ball  and  fills  the  orbit. 

Fig.  172 


Gliosarcoma  of  the  right  orbit,  secondary  to  the  left  eye. 


c.ikciMj.M.i  or  rill:  okhit 


2()9 


Myosarcoma  liiniois  lepoited  as  rhabdomyomas  are  probably 
embryomas,  alrhoimb  such  nniiors  mijihr  bt-  dcriNecl  from  the  ocular 
muscles.  (  )iu  i;isi'  ot  Uumn  om;i  has  bit  ii  described.  iMidothehomas 
ma\  reseinbli'  Icioiin  onias,  and  (hfKi  tut  lal  stains  ma\  be  necessar\' 
bifoif   the   iiuestioii   can    be   decided. 

I  he  oibiral  sarcomas  tend  to  early  metastasis,  and  \\h(n  uniovcd 
recuiieiice   iisuall\    occurs   in   one  or  two  years. 

Symptoms.  The  e\  e  is  displaced  directly  forward  d  the  tumor  is 
situatetl  within  the  muscle  cone  ( Fi^.  171),  or  in  the  opposite  dirt^ction 
frt)m  the  location  of  the  tumor  if  the  latter  is  situated  elsewhere  in  the 
orbit  (  Fi<i;.  173)  It  the  rate  ol  jzrowth  is  rapid,  the  tumor  is  usually 
soft  aiul  cellular;  if  slow,  it  is  hkeh'  to  be  Hbrous. 


Fig.  173 


Sarcoma  ot  the  orbit  invadinf;  the  temple. 

The  fibrous  t3'pe  can  be  distinguished  from  fibromas  only  by  micro- 
scopic examination.  Aspiration  ma}'  be  necessary  to  jdentify  cystic 
tumors  when  they  are  too  tense  for  fluctuation.  Orbital  tumors  on 
account  of  their  protected  situation  do  not  admit  of  careful  physical 
examination. 

Treatment. — Removal  of  the  orbital  contents  is  the  only  treatment. 
Recurrence  is  the  rule.     The  fibrous  tumors  permit  of  local  excision. 

Carcinoma. — The  edge  of  the  lids  is  a  common  site  for  carcinoma. 
It  ma\'  spread  over  the  conjunctiva  (Fig.  174)  or  outward  over  the 
skin   (Fig.   175),  or  rarely  it  ma\-  originate  in  the  conjunctiva  and   be 


270  TUMORS  OF  THE  ORBIT  AND  LACRYMAL  GLANDS 

Fig.  174 


Epithelioma  of  the  edge  of  the  hd,  extending  to  the  conjunctiva. 

Fig.  175 


EpitheHoma  of  the  edge  of  the  lid,  extending  over  the  skin. 


osTKoM.is  or  Tin:  oRiur  2/1 

confined  to  that  nunihranc  (  Fi^;.  \j()).  'Ilu-se  t\pes  are  usuall\  slowly 
giowinji.  The  .v-ra\  s  cure  the  hasal-eclled  t\pe  when  it  is  confined 
to  the  edj:;e  of  thi  lul.  \\  luii  tin-  coniuiuriN  a  is  involvi-d  (.-mKleation 
is   often    recjinred. 

Osteomas.-  Hon\-  tuniors  nia\  in\a(li-  tin-  oihit  piiinaril\-  Ironi  the 
periosteum  of  tlu'  oiiiital  wall,  oi  nia\  extend  tVoin  the  accessor}'  sinuses. 
Thf  t'omui  are  Kss  common  anti  de\clo]i  without  known  cause.  '1  he\' 
are  firm,  irre«i,ular,  nodular  tumors  not  differing;  from  osteomas  else- 
where, and  are  formed  of  a  dense  cortex  with  usuall)'  a  cancellated 
centre. 

Fic.  176 


Primar\'  epithelioma  of  the  conjunctiva. 


Those  which  develop  from  the  accessory  sinuses  arise  from  the  peri- 
osteum lining  these  cavities.  Their  starting  point  may  be  within  the 
ethmoid,  the  sphenoid  or  the  supra-orbital  cells  (Fig.  177),  and  they  are 
at  first  confined  within  the  w  alls  of  the  cavity  where  the}-  originate.  As 
they  grow,  the  w^alls  expand,  the  weakest  one  gives  w^a}-,  and  the  tumor 
bulges  into  the  orbit  or  nose  or  even  into  the  cranial  cavit}-.  The  tumors 
are  at  this  stage  surrounded  by  the  walls  of  the  sinus  in  which  they 
develop.  They  are  formed  of  a  cancellated  centre  and  a  dense  cortex, 
and  are  covered  b}-  periosteum.  The  bony  wall  of  the  cavit}*  ma}' 
become  eroded  and  the  tumor  becomes  exposed  to  the  surface  or  com- 


272 


TUMORS  OF  THE  ORBIT  AND  LACRYMAL  GLANDS 


municates  with  the  surface  by  a  sinus;  in  this  case,  suppuration  commonly 
occurs  and  may  extend  to  the  surrounding  tissues.  Occasionally  the 
tumor  becomes  loosened  and  lies  like  a  sequestrum  m  the  bony  cavity. 
As  the  tumor  grows,  the  surrounding  parts  yield  to  the  pressure,  and 
limiting  the  discussion  to  the  orbit,  the  eyeball  is  dislocated  and  the 
optic  nerve  may  become  compressed. 

Diagnosis. — The  two  kinds  of  orbital  osteomas  are  easily  differentiated. 
Those  which  develop  from  the  orbital  surface  are  irregular  and  nodular 
while  those  which  originate  within  an  accessory  sinus  cause  uniform 
bulging  and  are  frequently  accompanied  by  suppuration  of  the  affected 

Fig.  177 


Osteoma  of  the  supra-orbital  sinus.     The  roof  of  the  orbit  has  been  perforated  and 
an  irregular  nodule  thrust  within  the  orbit. 


sinus.  Osteomas  of  both  types  grow  very  slowly,  which  distinguishes 
them  from  the  sarcomatous  growths  of  the  orbit.  Other  tumors, 
adenomas  of  the  glands,  cysts,  and  lipomas  are  distinguished  by  their 
softness. 

Treatment. — Those  which  grow  from  the  orbital  surface  may  be  re- 
moved through  the  orbit.  Those  which  grow  from  the  accessory  sinuses 
may  be  reached  by  the  incisions  which  are  usually  employed  in  opening 
the  sinuses.  The  tumors  when  exposed  may  be  removed  entire  when 
pedunculated  or  piecemeal  when  attached  by  a  broad  base.  When  the 
cranial  cavity  is  invaded,  the  danger  of  infection  adds  very  materially 
to  the  operative  risk.     If  the  moment  of  opening  the  cranial  cavity  can 


CYSTS  <)l    THE  OKHir  27:i 

be    anticipated,   and    is    preceded    l\\    carctiil    disinfection    and    l()ll(nved 
bv   adequate   diaina«;c,   the   added   dan<ier   is   not  j;reat. 

Endotheliomas. —Endotheliomas,  which  jiroliahlv-  are  usuail}-  classed 
as  Hbrosarconias,  form  dense,  nodular,  slowlv  j^rowing  tumors.  In 
structure  the\  show  many  large  vessels  with  cells  arranged  closelv 
about  them.  1  he  cells  are  more  nearly  fusiform  than  is  usually  the 
case  in  endotheliomas.  In  clinical  course  they  resemble  other  endothe- 
liomas closel)-,  and  when  removed  locally  do  not  tend  to  recur.  Many 
of  these  tumors  spring  from  the  lacr}'mal  gland.  The\'  probabl}'  belong 
in  the  group  of  mi.xed  tumors,  since  cartilage  is  sometimes  found  in 
them.      \  erhoeff'  regards  them  as  of  epithelial  origin. 


Fig.  178 


Dermoid  of  the  outer  canthus  of  the  right  eye. 

Cysts. — Dermoid  Cysts. — These  are  relatively  common.  They  are 
situated  either  in  the  outer  (Figs.  178  and  179)  or  inner  angle  of  the 
eye  (Fig.  180).  Those  of  the  outer  angle  may  occupy  a  position  entirely 
upon  the  temple  (Fig.  181),  and  may  have  a  communicating  lobe  within 
the  orbit.  They  form  rounded  elastic  tumors,  over  which  the  skin 
glides  freely.  They  ma\'  be  confused  with  cerebral  hernias  when  located 
at  the  inner  canthus.  Removal  is  ordinarily  eas}',  but  when  located 
at  the  inner  angle  difficulty  may  be  experienced  in  separating  them 
from   the  lacrj'mal  apparatus. 


IS 


^  Jour.  Med.  Research,  1905,  xiii,  319. 


Fig.  179. 


Dermoid  of  the  outer  canthus. 
Fig.  180 


Dermoid  of  the  inner  canthus  of  the  left  eye. 


n  M(JkS  Ol     rill:    l.ICk) M.IL   CL./XDS  L'T.") 

Teratomas.  I  lusi-  have  Ihcii  cltsciilHcl  in  the  orbit.  I'hey  are  not 
oriiiiiialh  ailluiiiit  to  siii  rouiulinjz;  tis.sues  unle.ss  thev  In-eome  inflamed; 
in  this  case  th(\  ina\  perforate  either  externally  or  into  the  orbital 
contents. 

Cerebral  Cysts.  I  luse  are  .soiiKtimes  founc!  in  the  orbit.  1  hey  mav 
contain  ininin«:cal  Huid  only,  or  also  portions  ol  brain  substance.  \\  hen 
they  an-  located  at  the  inner  an}i,le  they  may  resemble  a  distended 
lacrimal  sac  or  a  dermoid  c}st;  but  are  differentiated  from  other  orbital 
c\sts  b\-  the  absence  of  bone  in  the  rej2;ion  they  occup\  . 

Serous  Cysts  Fluid  coUectmu;  about  Tenon'.s  capsule  ma\-  form 
a  c\'st,  most  often  at  the  trochlea.  Blood  clots  following  iniur\'  some- 
times  result   m    the   foiniarion   of   cysts. 

Vu).  i8i 


Dermoid  of  the  outer  angle  of  the  orbit  extending  upon  the  temple. 

Hemangiomas. — Hemangiomas  may  exist  independently  within  the 
orbit  or  the}'  ma}*  extend  from  similar  tumors  of  the  face.  When  they 
reach  the  skin,  the  color  and  the  consistency  suggest  their  nature. 
W  hen  the}"  lie  deep,  their  nature  may  be  difficult  to  determine. 

Lipoma. — True  lipomas  have  been  reported,  though  they  are  very 
rare.  Not  infrequently  rumors  producing  dislocations  of  the  eyeball 
are  diagnosticated  as  lipomas,  but  in  the  course  of  the  removal  a  deep- 
lying  tumor  which  carries  the  orbital  fat  upon  its  summit  is  discovered. 
Operators  have  failed  to  recognize  the  more  deeply  h'ing  tumor,  mis- 
taking the  orbital  fat  removed  as  representing  the  entire  disease. 

Timiors  of  the  Lacrymal  Glands. — Adenomas,  cAsts,  endotheliomas, 
and  carcinomas  are  occasionally  observed  in  the  lacrimal  glands. 
The  eyeball  is  displaced  inward  and  downward.  The  rate  of  growth 
and   the  physical  character  of  the   tumor  often   suggest  the  diagnosis. 


CHAPTER    XXI  I  I 

TUMORS   OF  THE   FACE 

Carcinoma. — The   face   is   one   of  the   common   seats   of  carcinoma, 
fully  lo  per  cent,  of  all  occurring  in  this  region  (Heiman).    Two  distinct 

Fig.  182 


Multiple  basal-celled  epithelioma  of  the  face. 

types  may  be  distinguished — (a)  the  superficial  (cancroid  of  the  old 
writers,  the  basal-celled  cancer  of  Krompecher),  and  (b)  the  deep  form. 
Carcinoma  of  the  lip  is  the  most  important  example  of  this  type. 


SL  I'l.kl  IC.I.IL    TYI'I:   Ol    riMfJRS  Ol    THE  I' ACE  277 

Superficial  Type.  I'his  type  occurs  most  tVe(iuentl>-  between  the  orbit 
(Fig.  1.S2)  aiul  the  superior  labial  fold  (Figs.  1S3  and  184)  extending 
backward  to  the  ear  (Fig.  185),  and  is  occasionall)-  seen  on  the  temples 
;iiui  thr  niik.  Musi-  tumors  arc-  characreri/.ed  by  their  slow  growth, 
which  caused  tin  ni  tormerlv  to  be  classed  apart  from  carcinomas  under 
the  term  cancroid.  Thev  begin  most  fre(}uentl\'  as  superficial  scaling 
lesions  (Fig.  186),  which  resemble  closel\'  and  are  perhaps  identical  with 
seborrheic  patches.  The  scale  after  a  time  is  replaced  b\-  a  scab;  that 
is    to   say,    the    first   covering   is    made    up   of  desquamated    epithelium 


^. 


Basal-celled  epithtlioma  of  tlu-  ala  of  the  nost. 

which  has  undergone  imperfect  involution,  while  the  subsequent  cover- 
mg  (the  scabj  is  made  up  of  serum  which  has  escaped  and  coagulated, 
being  a  consequence,  therefore,  of  the  loss  of  the  epidermis.  The  removal 
of  the  scab  is  attended  by  more  extensive  bleeding  than  occurs  in  the 
scaling  stages.  These  two  conditions  are  important  to  bear  in  mind, 
for  the\-  represent  the  line  between  the  benign  and  the  malignant. 
Man}'  Aears  are  frequently-  consumed  in  the  transition. 

Small  warts  (Fig.  187)  may  precede  the  development  of  facial  carci- 
noma.    In  these  instances  there  is  an  increasing  hardening  about  the 


Fig.  I 


Epithelioma  of  the  bridge  of  the  nose. 
Fig.  185 


Basal-celled  epithelioma  of  the  ear. 


]■{('..    |K^ 


J 


^^ 


Earl\-  basal-celled  epitlielionia  of  rlie  temple. 
Fig.  187 


Papilloma  of  the  cheek  which  has  remained  unchanged.     Behind  it  is  a  well-defined 
carcinoma  which  developed  from  a  similar  wart. 


280 


TUMORS  OF  THE  FACE 


base  of  the  wart,  which  continues  until  the  physical  characters  of  carci- 
noma, namely,  induration  and  cancer  plugs,  are  to  be  made  out.  Years 
may  be  required  for  the  development,  but  usually  the  time  is  shorter 
than  in  the  preceding  type  and  the  disease  runs  a  correspondmgh'  more 
rapid  course.  Each  of  these  varieties  extends  gradually  in  extent,  with 
but  little  tendenc}^  to  invade  the  depth.     Usually  the  surface  of  the 

Fig.  i88 


Epithelioma  of  the  face  covered  with  a  dense  brown  scab  hiding  the  granular  surface 

beneath. 


ulcer  is  covered  by  a  thick  brownish-gray  crust  (Fig.  i88)  which  may 
quite  hide  the  ulcer.  When  this  is  removed  a  bleeding  granular  surface 
remains  surrounded  by  a  slighth^  raised  border  (Fig.  189)  which  is 
dense  on  palpation.  The  deeper  tissues  are  usually  not  affected,  but 
deep  ulceration  may  result  (Figs.  190,  191,  and  192).  The  ulcers  are 
usually  irregularl}^  circular,  but  may  assume  any  form  in  the  later  stages. 
The  area  occupied  by  them  may  after  many  years  come  to  be  as  large 


sL  rr.Riici.ii.  T)  />/■:  oi   n mors  m  rui-  rici: 


281 


:is  tin-  IkiiuI   ..i    hnger  (Fi^.    193J.     Occasioiuilh  ,  iiisicd  of  ,iir(  r  lomia- 
tiDii,  |-»i()ni.iinu   minors  ni:i\-  form   (  l'"i^.   \'-)\). 


Epithelioma  of  the  face,  showing  a  clean  granular  base  with  a  well-defined  border. 

Fig.  190 


Basal-ccllcd  cpirhclioma  of  the  face,  forniinu  a  deep  ulct 


Fig.  191 


Deep  epithelial  ulceration  from  a  basal-celled  epithelioma  of  the  lower  lid. 

Fig.  192 


Deep  ulceration  of  the  face  from  a  basal-celled  epithelioma. 


Diii.r  '/)/'/■:  fji  TtMuks  or  the  i'.ice 


2K\ 


.\Krast;isis  ilois  nor  occur,  if  ;it  all,  until  a  considerable  surface  has 
been  cltsri()\  td.  iiu-  pcripluiai  (.xrtnsion  ni  one  direction  is  some- 
times accompanieil  b\  cicarn/.ation  at  another  part  of  the  border  'Fig 
195).  riu-  ulcer  nia\  actually  heal  o\cr  ni  |>laces  at  the  border  or  in 
the  centre  {V\^.  196).  1  hey  are  often  multiple,  a  dozen  or  more  being 
scattered  over  the  face  and  neck.  When  multiple,  they  usually  repre- 
sent different  stages  of  development  and  are  usually  confined  to  persons 
of  sandy  complexion  much  exposed  to  the  elements.  I  his  type  has 
been  called  sun  cancer}  Sooner  or  later  the  regional  glands  become 
involved  and  these  growths  then  follow  the  course  of  the  deeper  t\pe. 


Fic.  10; 


Extensive  rapidly  growing  epitfielioma  of  the  ear. 

Sometimes,  from  invasion  or  infection  of  the  brain,  death  by  meningitis 
may  supervene  without  the  formation  of  metastasis;  or  hemorrhage 
may  occur  from  invasion  of  some  of  the  deeper  vessels.  Still  more 
frequently,  by  local  extension  the  soft  tissues  of  the  mouth  are  destro}ed, 
nutrition  is  interfered  with,  and  the  patient  dies  from  exhaustion,  or  a 
septic  aspiration  pneumonia  supervenes. 

Deep  Type. — This  form  ma}'  occur  on  the  neck  or  the  temples,  but  is 
most  frequent  by  far  on    the   lips,  241  out  of  490  cancers  of  the  face, 

^  Hyde,  Amer.  Jour.  Med.  Sci.,  1906,  cxxxi,  I. 


284 


TUMORS  OF  THE  FACE 


according  to  Fredenberg,  being  in  this  region.  Tliey  occur  twenty  times 
on  the  lower  lip  to  once  on  the  upper,  and  hence  cancers  of  the  lower 
lip  may  be  taken  as  the  type  of  the  deep  cancers.  The  greater  frequency 
in  males,  409  in  473  cases  according  to  Neiman,  has  led  to  the  supposi- 
tion that  the  proclivity  of  men  to  outdoor  life  and  the  habit  of  smoking 
are  important  etiological  factors.  Outdoor  life  does,  in  fact,  produce 
drying  and  subsequent  cracking  of  the  lip,  and  this  condition  is  fre- 
quently the  starting  point  of  the  tumor.     Similarly,  irritation  produced 

Fig.  194 


Epithelioma  of  the  ear,  forming  a  polypoid  mass. 

by  a  broken  tooth  or  by  a  pipestem,  either  because  it  is  rough  or  because 
it  may  wear  the  teeth  sharp,  may  act  in  like  manner.  Seborrheic  patches, 
fissures  that  refuse  to  heal,  indolent  ulcers  (Fig.  197),  and  papillomas 
(Figs.  198  and  199)  may  likewise  serve  as  the  starting  point. 

Whatever  may  be  the  lesion  of  origin,  the  subsequent  course  in  an}^ 
case  is  marked  by  an  increased  induration  which  is  harder  to  the  touch 
than  an  inflammatory  swelling.  With  the  loss  of  the  protecting  epi- 
thelium there  is  a  tendency  to  bleed  readily  when  the  incrustation  is 
removed.     The  pain  at  this  stage  is  due  to  the  excoriation  rather  than 


DEEP   7)  /'A   Ol    ri  MORS   Ol    Till:   I  .ICE 


2X5 


to  invasion  by  rlie  urowtli.  l'suall\  ,  as  v\\\\\  as  rhc  excoriation  is  noted, 
oanccT  plu^s  ina\-  In-  seen  at  the  ((i^c  of"  the  iiUci.  These  are  Hne  white 
points  like  mmiiie  eonudoiies,  whuli  rie(]iienil\  ina\  he  pressed  out 
by  grasping  ih(  hp  tuinl\  between  ili.  ihimib  and  Im-.i.  I'hese,  with 
the  shi<!;.u;ish,  desiiuainatinw;,  or  encrusted  suilaee  and  indurated  border, 
characteri/e  the  disease.  Tliere  is  iisiiall\  no  paljKible  enlar{!;enient 
ot  the  i;hinds  at  this  sta<!;e,  but  cells  acKaiuin^  aionfz;  the  i\nipiiatics 
between  the  muscle  fibers,  even  as  far  as  the  glands,  can  usualU  be 
demonstrated   witii    the   microscope. 


Epithelioma  of  the  nose;  the  upptr  border  is  heahiig,  while  the  lower  border  is 

extending. 


brom  this  stage,  piling  up  of  the  newh'  formed  tissue  ma^-  produce 
a  fungiform  mass  (Figs.  200,  201,  and  202),  or  there  mav  be  ulcera- 
tion if  the  recently  formed  tissue  breaks  down  (Fig.  203),  or  both  ma\- 
occur  simultaneously  in  different  parts  of  the  lesion  (Fig.  204).  In 
some  instances  the  epithelial  proliferation  takes  place  in  the  substance 
of  the  hp  without  destroying  the  epidermis  covering  it  (Fig.  205).    After 


286 


TUMORS  OF   THE  FACE 


an    interval,    the    overlying    epithelium    is    destroyed    and    crateriform 
openings    are    formed.      The    result    in    all    cases    is    the    same.      Cells 

Fig.  196 


Epithelioma    healing   spontaneously,    marked    by   the   formation   of  a    scar   which 
retracts  the  tissue  from  all  sides. 

advance  along  the  lymphatics  to  a  constantly  increasing  distance,  and 
the  submental,  submaxillary,  and  cervical  glands  are  successively  mvaded 

Fig.  197 


Ulcer  of  the  lip  beginning  induration. 

(see  chapter  on  Tumors  of  the  Neck).     The  submental  gland,  the  first 
to  be  affected,  may  be  detected  as  a  small,  hard,  movable  body  just 


i)i:i:i'  TYi'E  oi  r I  MORS  or  the  i  .ice 


•isi 


In-hind    the  point  of  tlie  chin.      \\\    piishinj^   the   patient's   head  gentlv 
forward   and  droppinj^  the  chin  in  order  to  relax  the  muscles,  the  gl^ind 


IK,.    P;S 


Hard  papilloma  of  the  lip,  with   malignant 
mvasion  of  the  base. 


A  flat  papilloma  presenting  early 
malignant  change. 


Fig.  ::oo 


Fungiform  carcmuma  ut  iut.  up.  ut  slow  growth. 


288 


TUMORS  OF  THE  FACE 


may  be  most  easily  reached.     The  destruction  of  the  Hp  continues,  and 
the  patient  is  rapidly  reduced  from  bleeding,  interference  with  nutri- 


FlG.  20I 


Fungiform  carcinoma  of  rapid  growth. 


Fig.  202 


Fungiform  carcinoma  of  the  Up  surrounded  by  diffuse  infiltration. 


/>/■;/■;/'  TYi'i.  or  tumors  oi  tiii:  i  .u.l 

Kic.  203 


2S0 


Deep  ulceration  of  a  rapidh'  growing  lip  carcinoma  in  a  ho\-,  aged  sixteen  \ears. 

Fig.  204 


Epithelioma  ot  the  lip,  showing  ulceration  and  fungous  formation  simultaneous!}- 
19 


290 


TUMORS  OF   THE  FACE 


tion,   and  pain  which   arises  from  invasion  of  the  nerves,   particularly 
the  mental. 

The  extension  along  the  mucous  membrane  may  reach  far  back  into 
the  mouth  and  make  deglutition  painful.  The  exposure  of  the  respira- 
tory organs  to  this  source  of  infection  frequently  leads  to  pneumonia; 
or  the  extension  of  the  growth  to  one  of  the  large  vessels  ma}^  result 
in  a  fatal  hemorrhage.  In  the  most  slowl}^  growing  types  the  chief 
field  of  activity  is  frequently  the  lymphatic  glands.     The  glands  suc- 

FiG.  205 


Epithelioma  of  the  Hp  without  ulceration. 

cessively  become  enlarged  until  massive  tumors  are  formed  which  may 
ulcerate.  The  lip  in  rare  instances  may  be  invaded  by  these  glandular 
ulcerations,  making  it  appear  as  though  the  lip  ulceration  were  secondary 
to  the  disease  in  the  neck.  In  these  cases  the  glandular  disease  over- 
shadows the  original  tumor?  and  together  with  the  diffuse  invasion  of 
the  tissues  of  the  mouth  and  neck  may  conceal  it.  The  history  as  given 
in  these  cases  may  be  that  the  disease  began  in  the  gland.  This  may 
raise  the  question  of  a  Ij^mphosarcoma,  but  the  density  of  the  tumor 
and    the    nodulation    prove    the    growth    to    be   carcinomatous.      The 


DEEP  TYPE  or  rr.MOKs  or  riir  r.iCE 


•I'M 


enlarging  {ihiiuis  iii;i\  i;iusc-  tlirticiiltv  in  icspiratioii  and  deglutition, 
either  troni  the  pressure  the\  exert  in  the  neck  or  in  tlie  niediastinuni, 
or  hy  in\  asion  or  compression  ol  the  ner\'c-.  I  he  slowly  mowinj^  t\'pes 
characten/ed  h\'  late  <;landiilai  nutastasis  usually  run  their  course  in 
from  two  to  five  years.  I'hose  m  which  the  ju;lands  are  affected  earl\' 
ami  Income  the  prominent  factor  usualh  run  rheir  course  in  six  months 
to  a  year  and  one-halt. 

When  this  t\"pe  of  ^row  th  occurs  ahout  the  orbit  the  e\e  is  quickly 
invaded  il'ii^.  206),  the  bone  is  attacked,  and  cerebral  invasion  may 
take   place.      Invasion  of  the  lymphatic  glands  of   the  neck  is  usuall\' 


1...    20'. 


Deep  carcinoma  ot  the  inner  canthus,  involving  tlie  nasal  cavitv  secondarily. 


early  and  extensive  and  invasion  of  the  vessels,  trachea,  and  esophagus 
soon  follows.  Large  fungiform,  ulcerating  bleeding  masses  frequently 
reduce  the  patient  quickly  b\'  the  disturbance  of  sleep  and  hv  pain, 
disordered  nutrition,  and  intoxication,  both  metabolic  and  bacterial. 

The  superficial  t}pe  develops  so  slowly  that  it  is  frequently  difficult 
to  determine  when  the  papilloma  or  seborrheic  patch  has  become  malig- 
nant. Even  the  microscopic  examination  may  not  give  positive  informa- 
tion. Whenever  the  removal  of  the  scales  gives  rise  to  bleeding,  par- 
ticularly when  the  scaling  has  been  replaced  by  incrustation,  it  is  safest 
to  regard  the  benign  stage  as  past.  If  positive  induration  about  the 
border  is  present  the  diagnosis  is  beyond  question. 


292 


TUMORS  OF  THE  FACE 


In  the  deeper  type  the  problem  of  determining  when  the  lesion  has 
become  malignant  is,  unfortunately,  usually  easy.  The  early  stages 
are  nearly  always  past  and  the  positive,  evidence  of  carcinoma  is  at 
hand  when  cases  come  under  observation.  Albert's  statement  that 
there  is  never  any  difficulty  in  the  diagnosis  of  carcinoma  of  the  lip 
unfortunately  meets  with  few  exceptions.  Sometimes,  induration 
about  the  fissured  lip  may  raise  the  question  of  epithelioma,  but 
the  tenderness,  the  evident  subepithelial  induration,  and  the  greater 
elasticity  distinguish  such  cases  from  epithelioma.  The  hard,  horny 
papillomas  occurring  on  the  lips  of  males  beyond  middle  life,  even 
when  not  painful  or  indurated,  should  be  regarded  with  grave  suspicion. 
It  has  happened  twice  in  my  experience  that  such  lesions  which  did 
not  give  evidence  of  malignancy  on  microscopic  examination  were, 
nevertheless,  followed  by  speedy  recurrence  when  excised. 

Fig.  207 


Chancre  of  the  upper  Hp. 


Diagnosis. — Lupus,  though  relatively  uncommon  in  this  country,  is 
sometimes  seen  upon  the  face,  and  bears  some  resemblance  to  super- 
ficial epithelioma.  It  usually  begins  in  young  persons;  the  borders 
are  brownish,  softer,  and  more  rounded  than  in  epithelioma. 

A  differentiation  must  be  made  particularly  from  tuberculosis  and 
syphilis.  Tuberculous  lesions  seldom  invade  the  lower  lip.  When 
they  attack  the  upper,  they  occur  about  the  alae  of  the  nose  away  from 
the  vermilion  border.  The  age  of  the  patient,  the  chronicity,  and  the 
greater  density  of  carcinoma  make  the  chance  of  error  in  distinguishing 
between  the  two  conditions  very  slight. 


/'R(j(:.\(js/s  or  ri  \U)i<s  oi    riii:  i  u:e 


2n.s 


Syphilis  IS  soiiuriiius  (.oiilusccl  wiili  (.arcmouKi.  I  In-  chronic  lesions 
arc  usually  siruand  about  tin-  uosi-,  an-  rcnitorni,  break  clown  readily, 
anil  ha\'e  a  solt  bonier.  ()ilui  i\  uUiicc-  of  syphilis  nia\'  exist.  If  any 
dcjubt  exists,  the-  tlura|Hutic  test  may  be  applied.  In  primary  syphilitic- 
lesions  of  the  lip  (I'l^s.  207  and  20H;  the  supeiheial  ulceration  ma\ 
simulate  epithelioma,  but  the  cancer  plu<2;s  are  absent,  and  the  inHltration 
about  the  border  is  ob\  lously  unattached  to  the  epidermis.  The  onset  is 
rapid  and  the  glandular  swellings  are  sensitive  and  less  circumscribed  and 
dense  than  in  carcinoma,  and  are  present  from  the  first  appearance 
of  the  ulcer.     A  few  instances  have  been  reported  in  which  trichinosis 


Chancre  of  the  lower  hp. 

of  the  lip  has  been  mistaken  for  carcinoma;  and  the  presence  of  both 
diseases  at  one  time  has  been  reported. ^  Caution  is  necessary  in  differ- 
entiating these  conditions,  for  in  trichinosis  of  the  skin  the  epithelial 
proliferation  is  extensive  and  closely  simulates  carcinoma. 

Prognosis. — The  superficial  t\pe  gives  b}'  far  the  best  prognosis  of 
all  the  malignant  epithelial  tumors.  In  fact,  if  diagnosticated  at  all 
earl}'   permanent  cure   may   confidently   be   expected.     This   is  due   to 


^  Babler,  Ann.  Surg.,  1908,  xlvii,  },],z. 


294  TUMORS  OF  THE  FACE 

the  lateness  of  regional  and  glandular  metastases.  The  deep  variety, 
on  the  other  hand,  shares  with  carcinoma  in  general  a  grave  prognosis. 
Carcinoma  of  the  lip  furnishes  frequent  proof  of  this  statement;  not- 
withstanding the  exposed  position  of  the  growth  and  the  ease  of  diagnosis, 
the  percentage  of  permanent  cures  is  not  much  over  25  per  cent.  These 
unfavorable  results  may  in  fact  be  even  dependent  on  the  earliness 
of  the  diagnosis.  At  this  time  the  lesion  is  small,  and  the  disposition 
to  do  a  slight  operation  for  cosmetic  reasons  is  so  strong  that  local 
excision  is  practised  and  the  glands  are  not  molested  unless  there  is 
palpatory  evidence  that  they  are  diseased;  and  even  when  such  is  the 
case  only  those  unmistakably  affected  are  removed. 

The  results  in  carcinoma  of  the  lip  have  proved  that  the  early  diag- 
nosis in  carcinoma  which  is  loudly  demanded  is  without  result  if  an 
early  recognition  is  not  followed  by  a  radical  operation.  It  is  unfortu- 
nate that  carcmomas  of  such  vastly  different  clinical  characters  as  the 
basal-celled  variety  of  the  face  and  the  deep  variety  of  the  lip  and 
tongue  occur  so  closely  together.  The  ease  with  which  the  former  is 
cured  leads  operators  to  apply  similar  means  to  the  treatment  of  the 
latter,  and  the  delusion  is  strengthened  by  local  healing  of  the  lip  lesion, 
onl}^  to  be  followed  by  glandular  metastases  and  the  resistless  progress 
of  the  disease. 

Treatment. — The  benignancy  of  the  superficial  type  is  such  that  a 
more  conservative  plan  of  treatment  is  permissible  than  with  any  other 
type  of  carcinoma.  A  great  many  salves  and  escharotics  have  led  to 
healing  of  the  ulcer;  even  arsenic  administered  internally  has  been 
followed  regularly  by  its  disappearance  (Lassar).  Nevertheless,  dis- 
appearance does  not  always  signif}^  cure,  for  the  tumor  may  again  break 
down,  or,  what  is  more  important  still,  with  the  healing  of  the  local 
lesion  inaccessible  metastasis  may  be  provoked.  Even  in  this  simple 
type,  therefore,  a  rational  therapeusis  should  be  carried  out.  This  is  the 
type  of  lesion  in  which  the  x-rays  find  their  legitimate  application; 
superficial  carcinomas  of  the  face  undoubtedly  heal  under  their  influ- 
ence. Evidence  at  hand  now  seems  to  warrant  a  conclusion  as  to 
permanency  of  local  and  regional  results.  The  advantage  of  the  x-r3.YS 
is  that  the  cosmetic  results  are  better  than  after  operative  treatment. 
It  cannot  be  too  strongly  urged  that  in  order  to  retain  satisfactory 
results  with  this  agent  the  services  of  an  experienced  operator  are 
necessary.  When  the  tumors  are  very  small,  excision  or  the  use  of  the 
actual  cautery  can  be  employed  without  leaving  a  scar  of  any  conse- 
quence, and  with  less  annoyance  than  with  the  A;-rays.  After  glandular 
invasion  has  taken  place,  or  much  destruction  of  tissue  has  resulted, 
operative  treatment  is  the  only  permissible  therapeutic  means.  Wide 
removal  of  the  glands,  as  in  the  deep  type,  is  then  imperative. 


PLATE  I 


1.  Post,  belly  digastric. 

2.  Hypoglossal  nen-e. 

3.  Communicantes  hypnglossi  nerve 
4  Sternomastoid. 

5.  Des.  hypoglossi  nerve. 

<>  Sup.  thyroid  artery. 

7.  Com.  carotid  artery. 

8.  Com.  hypoglossi  nerve. 


9.  Phrenic  nerve. 

10.  Int.  jugular  vein 

11.  Masseter. 

12.  Submaxillary  gland 

13.  Digastric. 

14.  Ant.  belly  omohyoid. 

15.  Thyrohyoid. 

10.  Platv.«ma  myoides 


ikj:./T.\n:\r  or  ri  mors  oi  i  he  i  .ice  2'.i:> 

I  In-  ilii-piT  t\  |n-  ii-tiiiins  iii  all  iiisr:inv-(s  rlic  snmc  r:i(lic:il  rrcatmcnt 
thai  IS  apjiluil  to  caifiiionia  in  am  oilui  ic;;i()ii.  C  Oiisci  \  at  isin,  based 
on  a  iKsiii  toi  tile  l)t-st  cosmetic  usiilis,  lias  led  to  a  lni;li  ultimate 
iiiortalit\  ,  ami  should  al\\a\  s  he  resisted.  I  he  lessons  learned  ni  the 
operatiNi'  ticatnuni  of  eaiemoma  of  the  Imast  seem  to  l")e  lost  when 
a  similar  lesion  of  the  lip  is  eoiucined ;  sui;i,eons  should  he  as  Hiiii  in 
refusing;,  local  excision  in  the  one  case-  as  they  are  in  the  other. 

Not  alone  should  the  <;ro\\th  with  a  wide  mar^;in  he  removed,  but 
the  reiiional  hniiih  <:lands  as  well  (Plate  I),  whether  obviously 
diseased  or  not.'  I'hese  <;lands  are  located  m  the  trianf:;le  formed  by 
the  anterior  bellies  of  the  digastric  muscles  and  the  hyoid  bone.  I'hey 
are  usualh'  from  tw^o  to  six  in  number.  From  these  the  lymphatic 
vessels  pass  (a)  downward  across  the  hyoid  bone  and  terminate  in  a 
gland  on  the  anterior  surface  of  the  internal  jugular  vein  at  a  point 
where  this  vessel  is  crossed  by  the  omohyoid  muscle;  and  (b)  a  number 
of  channels  lead  outward  and  downward  to  the  submaxillary  glands. 
At  the  external  end  of  the  lip  channels  lead  to  the  inframaxillary  gland, 
which  is  situated  over  the  inferior  maxillary  bone  just  anterior  to  the 
point  of  crossing  of  the  facial  vein.  From  this  gland  channels  lead  to 
the  submaxillar\-  glands.  The  submaxillar}'  glands  in  turn  drain  into 
the  deep  cervical  glands.  The  mucous  membrane  of  the  lip  is  drained 
by  lymphatics  which  pass  directly  to  the  submaxillary  glands. 

The  chain  of  glands  to  be  considered  are  the  submental  and  the 
inframaxillary  in  the  first  link;  the  subh3'oid  and  the  submaxillary 
in  the  second  link;  apd  finally,  the  deep  cervical  in  the  third.  I  believe 
the  first  and  second  links  should  be  removed  in  all  instances.  If  these 
are  not  obviously  involved,  their  removal,  together  with  the  gland- 
bearing  tissue  in  this  region,  is  all  that  is  required.  Should  they  be 
obviously  carcinomatous,  then  the  third  link,  the  deep  cervical  glands, 
on  the  corresponding  side,  or  both  sides,  as  the  case  may  be,  should 
also  be  removed. 

The  removal  of  this  amount  of  tissue  can  best  be  made  b}'  an  incision 
passing  to  one  side  of  the  point  of  the  chin,  curving  over  to  the  inferior 
border  of  the  inferior  maxillary  bone,  extending  back  to  the  anterior 
border  of  the  masseter  muscle,  hence  downward  to  the  point  of  cross- 
ing of  the  omohyoid  and  the  sternomastoid  muscles  (tig.  209).  It 
should  be  noted  that  the  incisions  pass  on  one  side  of  the  point  of  the 
chin.  The  object  of  this  is  to  leave  the  skin  attached  at  this  point; 
if  it  is  loosened,  it  is  difficult  to  keep  the  flaps  in  position  over  the  point 
of  the   chin.      When    the   lesion   is   extensive   this   point  of  attachment 

'  D.  N.  Eisendrath,  Juur.  .Aiikt.  Mtd.  Assoc,  1906,  xKii,  986;  Hertzler,  Surg.,  Gynec, 
and  Ohst.,  1909,  ix,  80. 


296 


TUMORS  OF  THE  FACE 


cannot,  of  course,  be  preserved.  The  lymphatics  pass  on  each  side  of 
the  tissue  left  attached,  and  there  is  no  reason  for  its  removal.  The 
submental  space  may  be  easily  cleaned  out  by  pulhng  the  skin  aside. 
The  character  of  the  incision  in  the  hp  itself  depends  on  the  size  of 
the  lesion.  If  small  or  medium  in  size,  the  triangle  incision,  as  shown 
in  Fig.  209,  is  the  most  convenient.     If  very  extensive,  the  incision  of 

Fig.  209 


I,  omohyoid  muscle;  2,  sternomastoid  muscle. 

Grant  is  more  suitable,  to  which  is  added  the  incision  as  here  illustrated. 
If  it  becomes  necessary  to  remove  the  deep  cervical  glands,  the  vertical 
line  of  the  incision  may  extend  downward  to  the  clavicle  and  the  infra- 
maxillary  incision  may  extend  backward  to  the  tip  of  the  mastoid 
process.  A  second  transverse  incision  may  be  added  which  runs  parallel 
to  the  clavicle  and  just  above  it.  The  neck  incision  then  resembles 
that  recommended  by  Plummer  for  the  removal  of  tuberculous  glands 


I  Hi  ROM.  IS  or   Till.    I  .ICI-  21>7 

of  rlu'  lU'ik.  \\ nil  siuh  an  iiuisioii  ilu-  intiic  iliain  «>t  ti-rvical  ^laiuLs 
ami  (In-  L:,laiul-l>rai  inj;  tissiu-  can  he  icnioscil. 

As  m  tin-  hiiast,  tin-  ilissi  i.t  ion  sliouKl  In-^m  at  the  ponit  farthest 
from  tlu-  <iro\vtli  and  proceed  toward  the  lesion;  it  should  hc-^in  m  this 
cast",  tluittorc,  at  the  ani;li-  JHtwctii  the  onioh\()id  and  the-  stcrnoniastoiil 
muscles.  I  In-  \cssrlsand  trachea  are  laid  hare  up  to  th.e  interior  maxilla, 
exposing  the  sternohyoid  and  the  sternothyroid,  the  diagastnc,  and 
the  m\oglossiis  muscles.  It  is  not  necessar\-  tf)  remove  these  muscles. 
The  removal  of  the  sali\ai\  glands  facilitates  the  clearing  out  of  the 
regions  rhe\'  occup\'.  ShouKl  the  suhmaxillary  1\  nipli  inlands  he  toiind 
diseased,  the  incision  should  be  lengthened  as  indicated.  1  he  deep 
cervical  glands  may  be  removed  according  to  the  technicjue  recom- 
mended by  Crile.  Should  the  complete  dissection  of  both  sides  of  the 
neck  require  more  time  than  the  patient  can  safely  stand,  a  second 
sitting  ma\-  be  employed.  In  that  event  the  tumor  itself  should  not 
be  removed   until  the  end  of  the  second  operation. 

The  operation  above  described  serves,  with  slight  modifications, 
for  carcinomas  of  the  tongue,  floor  of  the  mouth,  and  buccal  mucous 
membrane.  The  question  of  secondary  operation  upon  the  neck  when 
hmph  gland  involvement  appears  after  local  treatment  often  presents 
itself.  If  the  glands  are  small  and  the  progress  slow%  block  dissection 
of  the  neck  may  be  tried.  When  large  glands  appear  soon  after  the 
local  growth  removal,  any  further  operative  treatment  seems  worse 
than  useless. 

Fibromas  (Moles  and  Warts). — Fibromas  of  the  face  are  encoun- 
tered in  various  forms.  The  flat  wart,  w^hich  may  be  pigmented  or 
not,  hair}'  or  smooth,  is  the  most  frequent  type  (Fig.  210).  The  common 
site  of  the  pigmented  variety  is  about  the  temple  (Fig.  211).  This 
variety  sometimes  gives  rise  to  sarcoma.  Fibromas  occurring  in  the 
course  of  a  nerve  are  less  common  and  are  usually  multiple.  Pibromas 
are  frequentl}-  combined  with  angiomas.  The  elephantiasic  type  of 
fibroma  may  also  be  mentioned,  although  it  is  infrequent  in  this  region. 
It  is  characterized  b}'  the  increase  of  the  loose  subcutaneous  connec- 
tive tissue,  which  results  in  the  formation  of  large  overhanging  masses 
of  loose  fibrous  tissue.  These  are  dependent  partly  upon  some  dis- 
turbance in  the  nerves.  Deep-seated,  circumscribed  fibromas  are 
rarelv  observed  m  the  face. 

Treatment. — The  small  non-pigmented  variety  may  be  treated  with 
escharotics.  The  pigmented  varietA'  when  localized  would  be  better 
excised.  When  broad  and  flat  the  surface  may  be  cut  off  with  a  razor 
so  as  to  remove  the  pigment.  It  must  be  admitted  that  while  this 
method  of  treatment  gives  the  best  cosmetic  results,  one  might  expect 
on    theoretical   grounds    that    such    treatment  might    stimulate    growth 


298 


TUMORS  OF   THE   FACE 


and   the  fprmation   of  metastasis,   though   no   such   accident   has    been 
reported.    This  does  not  hold,  however,  when  the  excision  is  deep  enough 


Fig.  210 


Hairy  papilloma  of  the  cheek. 
Fig.  2X1 


Papilloma  of  the  temple  of  many  years'  duration,  with  no  evidence  of  malignancy. 

to  remove  all  of  the  pigment  cells.  The  neurofibromas  seldom  require 
removal.  The  elephantiastic  type  may  require  extensive  operation  for 
their  removal. 


DERMOIDS   1)1     rill:    I  .ICK 


L".»!» 


Sebaceous  Cysts.  Ilu-  tact-  is  a  iclativtlv  ficciiitnt  site  for  wens. 
I  lu\  toini  loiiiuliil  tmiiois  artaclucl  to  rlu-  skin,  and  are  dense  when 
small,  hut  iiki\  lliuliiafi-  wlun  laii;c.  iHcausc  ot  the  fatty  tissue  in 
which  tlu\  he-,  they  may  project  but  little  above  the  surface  (I'ig.  212). 
Wlun  situated  over  the  malar  bone,  the\'  form  a  hemispherical  eleva- 
tion. Occasionally,  epithelioma  develops  about  the  point  of  attachment 
to  the  skill,  ami  an  mhltration  ai  this  iioint  should  arouse  suspicion. 
Ordinarily  excision  of  the  sac  results  m  a  cure. 

KiC.    212 


Sebaceous  c\st  of  the  cheek. 


Dermoids. — The  face  is  a  frequent  site  for  dermoids.  They  are 
situated  most  frequenth'  in  the  orbit,  the  lateral  regions  of  the  nose 
(Fig.  213),  the  temple  (Fig.  214),  and  the  region  of  the  ear.  They  form 
projecting  hemispherical  tumors,  which  are  soft  and  often  fluctuating. 
1  he}'  are  not  movable  upon  their  base  and  are  unattached  to  the  skin. 
Their  site  is  characteristic.     Their  removal  is  easily  accomplished,  save 


300 


TUMORS  OF  THE  FACE 


that   in    some   instances    their   attachment    to    the    periosteum    is    very 
intimate. 

Lymphangiomas. — Tumors  of  either  simple  or  cavernous  type  may 
occur  on  the  face;  usually  the  division  between  the  types  is  not  sharp. 
The  cheek   (Fig.  215)  and  lip  are  the  most  frequent  sites,  though  the 

Fig.  213 


Dermoid  of  the  nose;  boy,  aged  twelve  years. 
Fig.  214 


Dermoid  in  front  of  the  ear  in  a  boy,  aged  eighteen  years. 

eyelids  have  been  the  point  of  origin  in  a  few  cases  (3  cases,  Meyer). 
The  disease  is  congenital,  though  the  tumor  may  be  so  small  at  birth  as 
to  escape  notice.  Like  the  angiomas,  their  subsequent  course  is  variable. 
In  general,  the  tendency  is  to  enlarge,  but  usually  not  so  rapidly  nor  so 
extensively  as   do   hemangiomas,    though  cases  have   been  reported  in 


j.).\i/'//.i.\(,j(j.M.is  oj   Tin:  I  .ICE  ::oi 

which  the  entire  one-half  of  the  face  has  been  involved.  \\  hcii  ot  lar^e 
size  the\-  ma\-  compress  the  hones  of  the  face  and  prevent  development 
(Wej^ner,  Trendeienhur^). 

They  arc  iisualU  unilateral,  Inir  ma\  he  bilateral.  When  localized 
in  the  lip  tlu-\  form  tumorous  masses  exceeding  several  times  the  thick- 
ness of  the  normal  skin,  to  which  the\-  are  usually  attached  In  the 
simple  c\stic  t\pc  the  skin  ma\  In-  frtn-.  1  luy  ma\'  be  soft  and  elastic, 
perhaps  slightly  compressible;  or  the\'  ma\'  be  dense  if  secondar\-  chanj^es 
in  the  connective  tissue  surrounding  them  ha\'e  taken  place. 

Fic.  2  1 ; 


m 


^  *. 


Lymphangioma  of  the  cheek. 

Those  involving  the  cheek  may  be  continuous  with  similar  tumors 
in  the  lip,  eyelid,  or  tongue.  They  may  be  confined  to  the  tissue  imme- 
diateh'  below  the  skm  or  mucous  membrane,  or,  as  is  more  commonly 
the  case,  may  involve  the  entire  thickness  of  the  cheek  and  protrude 
into  the  mouth  as  well  as  upon  the  face.  On  the  eyelid  lymphangiomas 
may  be  little  more  than  dilated  Ivmph  spaces  over  small  areas,  or  they 
ma\'  form  large  masses  which  involve  the  orbit.  They  are  made  up 
of  a  small  or  large  number  o.^  cavities  lined  with  endothelium. 

Secondary  changes  attended  b}'  the  production  of  fibrous  tissue 
frequenth'  occur.  These  changes  have  been  shown  by  Kuttner  and 
Loeb  to  be  inflammatoiA'  in  nature,  and  are  accounted  for  by  the  fre- 
quent exposure  to  infection  from  the  mouth.  These  changes  may 
tend  to  the  obliteration  of  the  spaces  and  to  spontaneous  cure. 

Diagnosis. — Their  congenital  origin,  their  location,  the  normal  condi- 
tion of  the  skin  over  them  and  the  peculiar  elastic  consistency  is  suffi- 
cient to  suggest  a  diagnosis.  Other  cystic  conditions  ma\"  be  confused 
with  hmphangiomas  in  the  absence  of  a  clear  history.     Among  these 


302  TUMORS  OF  THE  FACE 

are  cystic  dilatation  of  the  salivary  ducts,  the  location  of  which  will 
indicate  their  nature,  and  cystic  dilatation  of  the  labial  glands  which 
may  cause  a  marked  thickening  of  the  lips.  In  these  cases,  however, 
the  density  of  the  individual  cysts  and  the  mucinous  contents  are  dis- 
tinctive. A  case  of  echinococcus  cysts  of  the  cheek  has  been  reported 
from  V.  Bergmann's  clinic  The  history  might  suggest  and  the  contents 
would  demonstrate  the  nature  of  these  cysts. 

Thickening  of  the  Hps  may  be  produced  by  a  chronic  or  recurrent 
infection  of  the  mucous  membrane  of  the  lip  or  of  the  cheeks.  This 
is  especially  likely  to  occur  in  a  recurrent  erysipelas.  The  history  of 
such  attacks  and  the  absence  of  cysts  is  distinctive. 

Diffuse  lipomas  may  simulate  these  tumors.  They  are,  however, 
seldom  congenital,  are  not  attached  to  the  skin,  and  are  often  bilateral. 
Absolute  differentiation  may  be  made  by  puncture.  Both  conditions 
may  be  present. 

Hemangiomas  are  distinguished  by  the  bluish  tint  of  the  skin  and 
by  their  greater  compressibility.  When  puncture  becomes  necessary 
Lexer  advises  that  it  be  done  through  the  skin  and  not  from  the  mouth, 
because  of  the  lesser  danger  of  infection. 

Treatment. — When  the  lesions  are  sharply  localized  and  small  enough, 
excision  is  the  treatment.  This  is  seldom  possible,  however,  because  of 
either  their  size  or  their  anatomical  relations  with  the  facial  nerve  and  the 
salivary  ducts,  for  instance.  When  the  lip  is  involved,  a  wedge-shaped 
excision  may  be  made.  Incision  with  packing  has  been  emplo3^ed, 
but  with  uncertain  results,  either  on  account  of  infection  or  from  the 
subsequent  enlargement  of  small  cysts  which  escaped  notice  during  the 
operation.  Injections  of  iodine  or  zinc  chloride  have  been  used.  Lexer 
secured  a  partial  cure  by  the  use  of  a  i  per  cent,  solution  of  the  latter. 
The  patient  refused  to  complete  the  treatment. 

Hemangiomas. — The  face  is  the  seat  of  two-thirds  of  these  tumors, 
according  to  Trendelenburg,  and  of  his  170  cases,  two-thirds  were  in 
females.  They  are  located  most  frequently  about  the  nose  (Fig.  216) 
and  lips,  and  often  about  the  fetal  folds,  though  they  are  by  no  means 
confined  to  these  situations. 

Both  the  simple  and  the  cavernous  types  occur  in  the  face.  The 
racemose  variety  sometimes  involves  the  face  by  extension  from  the 
temple  (Fig.  217),  but  it  never  has  its  primary  seat  in  this  region. 

Simple  Type. — There  is  no  sharp  dividing  line  between  simple  vascular 
dilatations  on  the  one  hand  and  cavernous  angiomas  on  the  other  hand. 
The  simplest  form  consists  of  a  single  central  vessel  with  numerous 
vessels  radiating  from  it.  This  type  is  usually  found  about  the  root 
of  the  nose  or  about  the  lower  eyelid,  and  has  been  compared  by  the 
Germans  to  a  flea  bite.     Strangely  enough,  it  is  almost  never  seen  in 


III..M.I\C.I().\1.IS  or    THE   I  .ICE 
Ik..  2i6 


:iO:i 


Hemangioma  of  the  tip  of  the  nose. 


Fig.  217 


Racemose  aneurysm  of  the  temple,  e.xtending  into  tlie  cheek. 


304 


TUMORS  OF   THE  FACE 


boys.  The  more  common  type  presents  a  flat,  livid  area  a  centimeter  or 
more  in  diameter.  These  are  the  so-called  birth  marks,  the  nevi  of  the 
dermatologists.  The  affection  at  birth  may  involve  the  entire  face.  It 
may  be  flat  with  the  surface  or  may  be  more  or  less  elevated.  The  course 
is  variable.  It  may  remain  stationary  and  grow  only  as  the  child  grows, 
or  it  may  disappear  spontaneously,  usually  on  account  of  the  occlu- 
sion of  a  feeding  vessel.      It  may,  on  the  other  hand,  grow  rapidly. 

Cavernous  Type. — This  type  is  found  usually  about  the  lips,  less  often 
about   the  eyelids   and   cheek   (Fig.   218).      It   may  form   a   protruding 


Fig.  218 


Ca 


vernous  nemangiomas. 


mass,  more  or  less  compressible.  It  usually  is  present  at  birth,  but  may 
come  from  trauma  or  without  demonstrable  cause.  It  may  be  so  small 
as  to  cause  merely  a  local  thickening  discernible  only  as  a  small  com- 
pressible enlargement.  Cases  have  been  reported,  on  the  other  hand, 
which  affected  the  entire  face  and  the  intracranial  vessels.  The  neigh- 
boring soft  parts  may  undergo  pressure  atrophy  and  the  dental  arch 
may  be  deformed.  These  large  tumors  sometimes  have  a  well-defined 
capsule.^ 

^  D.  J.  Cranwell,  Rev.  de  chir.,  1907,  xxxv,  557. 


R  iki.  ri  woA'.s  (ji   rill:  I  .u:i:  :'.<i.") 

liotli  r\pis  arc-  cliar;Krcir/<.cl  l\\'  rlu-ir  it-cl  color,  which  is  due-  lo  ihc- 
increase  in  nmnhn  and  si/c  of  the  vessels;  hut  when  rlie\  spring  troni 
rhi-  nion-  cleipl\  1\  inti  structuiis  the  skin  omi  ihiin  ina\  he  noiinah 
I  hi-  color  nia\  \ai\  lioin  a  hiiuht  retl  to  a  deep  hhu-.  I  he  tumors  are 
soft  and  coinpiissihle  and  nia\  rarely,  when  i  <innminicatin^;  with  a 
lar^e  arter\',  he  pulsatinu.  Pressure  pain  has  hi-i  n  notc-d.  Sometimes, 
lartie  dilated  \cssels  nia\  radiate  from  henian<;ioinas  and  add  niareiiall\' 
to  the  hulk  ot  the  tumor.  These  \essels  when  communicarinu  with 
those  of  the  orhit   may  cause  displacement  of    the  e\e. 

Diagnosis.  lluii  color  and  comjiressihilir)  make  recognition  easy. 
1  he  more  deeph  seated  ones  may  simulate  Ivniphangiomas,  hut  are 
more  compressible  than  the  latter.  Puncture  will  clear  up  all  doubt, 
but  blood  may  be  obtained  from  lymphangiomas  as  well  if  the  needle 
does  not  strike  a   ca\ity. 

Treatment.  The  nevi  ma\'  be  effectually  removed  by  shaving  oft' 
the  surface  epithelium  as  in  making  a  Thiersch  graft,  just  deep  enough 
to  open  the  vessels,  without  the  subsequent  transplantation  of  grafts. 
The  hemorrhage  is  controlled  b\'  hot  compresses.  The  epithelium 
reforms  in  a  few^  days.  In  areas  where  the  epidermis  is  not  removed 
deeph'  enough  the  vessels  escape  and  failure  results.  If  the  removal 
is  made  too  deep  the  entire  epithelial  la3'er  is  removed  and  the  epi- 
dermization  must  take  place  from  the  peripher).  Too  little  rather  than 
too  much  should,  therefore,  be  removed;  areas  not  cured  at  the  first 
trial  may  be  repeatedly  subjected,  to  this  treatment.  Blair  employs 
a  method  differing  from  this  in  that  the  removal  is  made  more  deepl}' 
and  the  resulting  defect  covered  by  Thiersch  grafts.  This  method  may 
be  employed  if  the  preceding  fails. 

Very  small  tumors  may  be  excised  with  little  scarring.  The  galvanic 
needle  is  the  preferable  method  of  treatment  of  angiomas  of  the  face, 
because  of  the  slight  scarring  which  results.  The  objections  to  this 
method  are  the  time  required  and  the  pain  which  it  causes.  Children, 
in  whom  the  treatment  is  usually  indicated,  require  a  general  anesthetic. 
In  the  ver\'  small  punctiform  angiomas  a  single  use  of  the  needle  will 
result  in  a  cure.  In  large  tumors  from  two  to  fifteen  applications 
will  be  required.  In  large  cavernous  angiomas,  which  are  developing, 
the  thermocauterr  may  be  required.  While  more  effective  than  the 
galvanic  cauter^',  the  scarring  is  greater,  but  in  rapidly  growing  tumors 
this  is  a  secondar}'  consideration.  Hot-water  injections  after  Bryant's 
method  may  be  employed  here.  In  the  very  large  tumors,  excision  of 
the  entire  mass  may  be  undertaken. 

Rare  Tumors  of  the  Face. — Lipomas. — Lipomas  of  the  face  are 
relatively  rare,  but  invasion  of  the  cheek  b\-  lipomas  of  the  neck  and 
mastoid  region  is  not  uncommon.  In  these  instances  the  condition  is 
20 


306 


TUMORS  OF   THE  FACE 


so  obvious  as  to  require  merel}'  mention  here.  Lipomas  of  the  face 
appear  usually  as  circumscribed  tumors  globular  in  form,  lacking  the 
lobulation  common   to   lipomas   elsewhere.     They   may   be   diffuse   and 

Fig.  219 


Endothelioma  of  the  upper  lip. 
Fig.  220 


"iijl(j- 


/> 


Rhinophyma. 


infiltrating.  The  globular  form  gives  a  pseudofluctuation  which  makes 
them  easily  mistaken  for  wens  or  other  cysts.  The  yellowish  color 
may  be  apparent  through  the  mucous  membrane,  while  cysts  usually 


A'. /A'/-  ri  WKJks  or  riii:  i.ice 


.{o; 


appt;ir   riansparnu   or   Miiish.      Cystic   l\  niphaii^ionuis  are   parricularh' 
likch    ro  caiisr  (.■ontiiMoii   m   cliaiiiiosis. 


i  ic;.  221 


"^^- 


'1  ^m0^ 


\^' 


,.-f"'''-?;W^'^iH 


:^ 


.  <-.Mi^ 


i    ■ 


y-^:  "^  ■:■■■: ':^'' 


■yj^t  .-    >..r.". 


^  J^. 


.^f^^; 


Adenoma  of  nose. 


Fig.  222 


^^r^K^  ^ 

■k 

1 

■ 

i 

J 

Br 

X 

"■ 

^ 

^ 

^^^^^^^^^ 

'  ^jH 

^ 

^^^^^^fc 

«.«««»- 

ft  4»^<i^li 

Sweat  eland  adenoina  of  the  face. 


Lipomas  are  often  combined  with  bloodvessels  to  form  angiolipomas 
which   frequentl}-  cannot  be  distinguished   from   hemangiomas.      These 


308  TUMORS  OF  THE  FACE 

are  usualh'  diffuse,  but  may  be  sharply  circumscribed  and  lobulated. 
There  may  be  an  absence  of  venous  bruit  and  compressibihty  even 
in  large  vascular  tumors.  A  preoperative  differential  diagnosis  from 
cysts  may  be  made  by  aspiration.  It  is  important  to  remember  that 
an  apparent  encapsulation  may  be  deceptive.  When  lipomas  are 
diffuse,  particularly  when  occurring  in  the  sucking  pad,  dissection 
is  frequently  difficult.  Accordingly,  when  they  grow  about  Stenson's 
duct  and  about  the  branches  of  the  facial  nerve  great  care  must  be 
exercised  in  their  removal.  It  is  frequently  necessary  to  remove  them 
piecemeal.  Those  occurring  in  the  parotid  region  when  not  freely 
movable  are  very  likely  to  be  mistaken  for  parotid  cysts.  Here,  too, 
great  care  is  necessary  in  removing  them  in  order  not  to  injure  the 
tributaries  of  Stenson's  duct. 

Leiomyomas. — These  have  been  observed.^ 

Endotheliomas. — Not  infrequently  endotheliomas  appear  on  the  cheek 
or  lips.  The\^  form  sharply  circumscribed  globular  tumors  fFig.  219) 
of  slow  growth.  When  removed,  t\\ty  tend  to  recur.  Their  structure 
may  confuse  them  with  spindle-celled  sarcomas,  and  extensive  study 
may  be  required  to  permit  a  differentiation. 

Adenomas. — Both  the  sweat  and  sebaceous  glands  not  uncommonly 
take  on  adenomatous  growth  fFig.  222)  and  form  firm  nodules,  which 
rarely  become  larger  than  a  hickory  nut.  They  differ  clinically  from 
the  endotheliomas  in  being  somewhat  softer,  but  usually  microscopic 
examination  is  necessary  for  differentiation.  They  occasionally  become 
malignant  and  should  be  excised. 

Rhinophyma. — Closely  associated  with  the  sebaceous  tumors  of  the 
face  is  a  similar  affection  limited  to  the  sebaceous  glands  of  the  nose. 
They  form  large  lobulated  tumors  producing  great  deformity  (Fig.  220). 
In  structure,  they  are  composed  of  a  great  hypertrophy  of  the  glands 
(Fig.  221). 

1  E.  Sehrt,  Beit.  f.  klin.  Chir.,  1907,  liv,  723. 


c  II  A  r  I   \:  k    X  X  I  \ 

llMOkS   ()!•    TIIK   NASAI.    lOSSA    AM)    IMIAinNX 
TUMORS    OF    THE    NASAL    FOSSA 

General  Conception.  Irue  tumors  of  rlu-  nose  are  rare.  I  he  beni;:n 
tumois  are  usually  the  result  of"  chronic  inflammation,  and  there  is 
reason  to  believe  that  inflammatory  processes  bear  an  important  etio- 
lojiical  relationship  to  many  of  the  mali<:nant  ones. 

Nasal  Polyps.-  These  tumors  are  edematous  pedunculated  fibroids, 
which  develop  from  the  mucous  membrane  of  the  upper  part  of  the  nasal 
cavit\',  particularly  from  the  ethmoid,  and  superior  turbinated  bodies. 
Less  often  they  arise  from  the  hiatus  semilunaris  and  the  ostia  ot  the 
accessor\'  cavities.  They  rarely  come  from  the  septum,  and  never  from 
the  inferior  turbinated  bodies  nor  from  the  floor  of  the  nasal  tossa.  The 
prime  factor  in  their  etiology  is  the  discharges  from  the  accessory  sinuses. 
Pohps  contain  the  glands  natural  to  the  mucosa  of  the  part  from  which 
the\'  grow.  These  glands  may  undergo  proliferation  from  the  chronic 
irritation,  or  some  ma}'  become  c\stic  on  account  of  occlusion  ot  their 
outlet  ducts.  Polyps  appear  as  whitish-gray  or  reddish  tumors,  which 
are  pear-shaped  and  either  simple  or  lobulated.  When  they  become 
large  they  adapt  themselves  to  the  cavity  in  which  they  grow.  They 
have,  because  of  the  mucinous  fluid  they  contain,  an  almost  translucent 
appearance. 

Symptoms. — A  polAp  may,  if  it  is  large,  project  into  the  pharynx 
and  interfere  with  the  movement  of  the  palate,  or  it  ma}-  disturb  the 
natural  drainage  of  the  accessory  sinuses  and  the  middle  ear.  To  these 
obstructive  efi^ects  ma\'  be  added  the  symptoms  of  the  original  sinus 
inflammation.  The  most  common  disturbance  is  the  obstruction  to 
normal  nasal  breathing. 

Diagnosis. — The  diagnosis  is,  as  a  rule,  easily  made  by  anterior  rhinos- 
copy, the  whitish-gray,  succulent  appearance  and  pol\poid  form  of  the 
growth  being  suflRcientl\'  characteristic.  B\-  moving  them  about  with 
a  probe  they  may  be  distinguished  from  h\  pertrophied  turbinates  or 
from  septal  exostoses.  The  diagnosis  of  pol\  p  having  been  made,  the 
present  state  of  the  accessor}-  sinuses  should  be  determined  as  a  part 
of  the  diagnosis.  Sometimes  this  cannot  be  done  before  the  removal 
of  the  polyps.     When  the  tumors  are  large  and  project  into  the  rhino- 


310  TUMORS  OF   THE  NASAL  FOSSA  AXD  PHARYNX 

pharvnx  their  relation  must  be  determined  b\'  posterior  rhinoscop)'. 
Simple  as  the  diagnosis  usualh'  is,  nasal  poh'ps  may  be  confused  with 
graver  conditions,  such  as  beginning  malignant  tumors,  congenital 
anomalies  (cerebral  hernias),  and  fibromas  of  the  pharynx. 

Treatment. — Removal,  while  easih'  accomplished,  preferably  with  the 
wire  snare,  is  but  the  preliminary  step  in  treatment.  Cauterization  of 
the  base,  which  was  formerly  recommended,  has  now%  in  the  light  of 
clearer  knowledge  of  the  pathogenesis  of  these  growths,  given  wa}''  to  a 
search  for  the  causative  factors  and  their  removal. 

Polypoid  Hypertrophy  of  the  Turbinates. — As  a  result  of  a  chronic 
inflammatory  process,  local  hypertrophies  of  the  mucous  membrane  of 
the  inferior  turbinate  bodies  ma}'  develop.  These  growths  resemble 
soft  papillomas  more  than  polyps,  and  are  frequenth^  mistaken  for 
them.  They  are  reddish  in  color,  irregularl}'  lobulated,  have  a  broad 
base,  and  are  attached  in  the  lower  portion  of  the  turbinate  bodies,  as 
can  be  determined  by  the  aid  of  a  probe. 

Treatment. — The  treatment  consists  in  their  removal  with  the  wire 
snare  or  galvanocauter}'.  Small  diffuse  portions  maA'  be  excised  with 
cutting  forceps  or  scissors.  In  addition  to  removal,  a  correction  of  other 
defects — chronic  h^-pertrophies  of  the  mucous  membrane  or  septal 
deviations  or  exostoses — insures  a  permanent  result. 

Hard  Papillomas. --Small,  hard  papillomas  made  up  of  squamous 
epithelium  are  occasionall}'  noticed.  The}'  occur  at  the  junction  of 
the  hard  and  soft  palate  or  in  the  anterior  portions  of  the  nose  where 
a  metamorphosis  of  the  epithelium  has  taken  place  as  a  result  of  chronic 
disease.  Removal  is  frequentlx'  followed  by  local  recurrence,  but  a 
transition  into  carcinoma  has  been  noted  only  a  few  times. 

Hemorrhagic  Septal  Polypi. — These  lesions  are  found  in  the  anterior 
part  of  the  nose  going  out  from  the  nasal  septum.  They  result  from 
the  chronic  ulcers  so  frequenth^  seen  in  rhinitis.  The}'  have  promi- 
nent bloodvessels  and  present  the  usual  characters  of  chronic  granula- 
tion tissue.  When  large,  they  ma}^  be  mistaken  for  tuberculosis  or 
malignant  tumors.  Their  location,  chronicity,  and  their  disposition 
to  bleed  are  characteristic.  They  ma}'  be  removed  by  curettage  or 
cauter}'.  Particular  care  should  be  taken  to  destro}'  the  border  so  that 
new  granulation  tissue  may  fill  in  the  defect. 

Rare  Benign  Tumors  of  the  Nose. — Many  tumors  more  or  less  related 
to  the  foregoing  are  sometimes  observed.  Their  exact  determination 
is  usuall}^  a  matter  of  laboratory  stud}'.  Adenoma,  adenofibroma, 
cysts,  enchondroma,  and  osteoma,  and  various  combinations  of  these, 
ma}'  be  observed.  Exostosis  and  ecchondrosis  may  be  indistinguish- 
able from  other  tumors  of  like  tissue  Polyps  with  predominating 
c}'sts  may  be  confusing,  simulating,  as  they  do,  cerebral  hernias,  and 


ri  WKjRs  or  rill:  s.is.ii.  loss.i 


:;ii 


tin-  lnrti\rllul;ii  sul>st;iiKc  of  polyps  resembles  fretjueiul)  true  iii\  .\»)ul 
siil>sr;iiu-e.  Sonurinus,  however,  an\-  of  the  t\pes  enumerated  may 
r;ike  on  tlu-  ili,miit\  of  imiioitaiit  tumois  ;iiul  fioni  their  si/e  cause 
pressure  atroph\  of  neighboring  structures.  Cerebral  hernias  some- 
times present  in  the  roof  of  the  nose  simulating  nasal  pol\ps.  1  hev 
may  produce  displacmuni  of  tin-  oibiral  plates  ot  the  ethmoid  ( Hfj. 
22;)  simulatint;  dermouls  of  the  niner  canthus.  I'heir  recofjnition  is 
important,  for  if  remoMcl  without   precaution,   meningitis  may  develop. 


Cerebral  hernia  of  the  vault  of  the  right  nasal  cavity. 

Treatment.— Snare,  cutting  instruments,  or  chisels  may  be  required 
for  their  removal.  After  removal,  careful  microscopic  stud}-  should 
be  made  in  order  to  detect  any  possible  malignant  portion.  Gliomas 
of  the  nose  have  been  reported.'  The  presence  of  glia  tissue  indicates 
that  the  growth  is  continuous  with  the  brain  or  represents  a  terato- 
matous   tumor  of  the  neighborhood. 

Malignant  Disease  of  the  Nose.-^  This  is  fortunately  a  rare  group 
of  tumors.  According  to  M.  Schmitt,  in  33,000  cases  of  disease  of  the 
nose  there  were  6  sarcomas  and  5  carcinomas.  These  resemble  each 
other  so  closelv  that  thev  may  be  considered  together. 


1  J.  P.  Clark,  Amer.  Jour.  Med.  Sci.,  1905,  c.wix,  769. 

-  For  a  complete  account  of  the  malignant  tumors  of  the  nose  see  Harmer  and  Glas, 
Deutsch.  Ztschr.  f.  Chir..  1907.  Ixxxix,  433. 


312 


TUMORS  OF   THE  NASAL  FOSSA  AND  PHARYNX 


Sarcomas. — The  small,  round-celled  tj^pe  is  the  most  frequent,  although 
spindle-celled  and  even  melanotic  types  have  been  observed.  The 
point  of  origin  may  be  the  lateral  wall,  the  septum,  or  the  neighboring 
sinuses,  particularly  the  antrum  of  Highmore;  but  this  point  is  usually 
impossible  to  determine  by  clinical  examination,  and  even  at  opera- 
tion, with  the  affected  region  exposed,  it  frequently  cannot  be  made 
out.    The  advent  of  the  tumor  is  often  preceded  by  a  prolonged  inflam- 

FiG.  224 


Sarcoma  of  the  nasal  fossa,  producing  a  displacement  of  the  right  nasal  bone. 


matory  affection.  Usually,  the  symptoms  which  bring  the  patient 
for  examination  are  those  of  nasal  occlusion,  though  sometimes  hemor- 
rhage ma}^  appear  first.  Frequently,  the  first  evidence  is  the  expansion 
of  the  nasal  bones  (Fig.  224),  producing  a  marked  bulging  of  the  side 
of  the  nose.  They  grow  very  rapidly  and  quickly  invade  neighboring 
regions,  namely,  the  orbit  and  antrum,  and  by  penetrating  the  cribri- 
form  plate  gain  access  to  the  cranial  cavity.  Sloughing  masses  some- 
times project  from  the  nose  or  into  the  pharynx. 


77    I/OA'.S   or   THE    flllKYW  WV.', 

Carcinoma.'  I  lu  sr  runiois  mkin  In-  cliiixid  (lom  ciil)()iclal  or  s(]ii;ini()iis 
ipitlulium  ot  tin  n;is;il  fossa  or  from  tlu  |)crfoiatc(l  sinuses.  Their 
growth  IS  rajMil  ami  tluir  cells  soon  lose-  tluir  type,  so  rliat  the  source 
of   onjiin   can    no   lonti,cr   hi-   (Kternnniil. 

Diagnosis.  I  he  rapiilir\  ot  ile\elopnienr  anil  the  e\rensi\e  nnasion 
of  the  surrounilin^  tissue  usuall\-  chaiactei  i/es  the  tumor  as  malig- 
nant. Mil'  microscopic  ilisrmction  hetweeii  mali<:nanr  anil  heni^n 
tumois  is  often  iliHicult  to  make.  .\lan\'  of"  the  heni}j,n  rumors  are 
cellular  anil  hear  a  very  close  resemhlance  to  malignant  tumors.  The 
difference  m  clinical  course  between  carcinoma  and  sarcoma  some- 
times permits  of  a  dif^^erennation.  Carcinomas  nearh  al\\a\s  occur 
after  the  forty-fifth  year.  Sarcomas  are  more  often  developed  from  the 
septum  and  the  carcinomas  from  the  lateral  walls.  Carcinoma  tends 
to  break  down  and  form  a  fetid  mass,  while  sarcoma  retains  an  intact 
surface  and  displaces  the  surrounding  tissue,  \'et  sarcomas  are  more 
prone  to  bleed.  The  microscopic  differentiation  is  often  difficult,  and 
may  require  a  special  technique. 

Treatment. —  Operative  removal  ma}^  be  tried.  Extensive  local  e.xcision 
is  important.  The  lymph  glands  of  the  neck  need  not  be  removed,  since 
metastasis  does  not  take  place  in  that  direction,  but  toward  the  base 
of  the  skull. 

It  is  questionable  if  a  case  of  either  of  these  tumors  has  been  cured. - 
This  is  easily  understood,  since  it  is  often  impossible  to  determine 
the  extent  of  the  growth  or  if  the  growth  has  already  taken  place  in 
lymphatics  about  the  base  of  the  cranium  and  in  the  deep  glands  about 
the  vertebral  column. 


TUMORS    OF   THE   PHARYNX 

Fibromas. — These  tumors  develop  from  the  vault  of  the  pharynx. 
They  are  said  to  occur  with  equal  frequenc}'  in  males  and  females 
before  puberty,  but  at  this  age  the}'  become  excessively  rare.  Curi- 
ousl\'  enough,  during  the  period  between  pubert}'  and  full  develop- 
ment the}'  are  found  exclusively  in  males.  They  are  very  vascular 
and  are  made  up  of  cellular  fibrous  tissue;  in  fact,  the  border  of  these 
tumors  is  sometimes  so  cellular  as  to  make  microscopic  distinction 
between  them  and  sarcoma  almost  impossible.  The  number  of  cases 
of  sarcoma  sometimes  reported  may  be  due  to  a  failure  to  recognize 
this  characteristic.     By  their   growth    they  hil    first   the    vault  of    the 

'  Drev  fuss,  Wien.  mcd.  Presse,  1892,  xx.xiii,  141 7. 

-  Herzfeld,  Berl.  klin.  Wochenschr.,  1900,  xxxvil,  796. 


314  TUMORS  OF  THE   NASAL  FOSSA  AXD  PHARYNX 

phaiynx,  and  extending  downward  below  the  soft  palate,  interfere  with 
deglutition  and  even  respiration.  They  may  encroach  upon  the  nasal 
fossa,  may  invade  the  accessory  sinuses,  and  may,  through  pressure 
atrophy,  enter  the  cranial  cavity. 

Symptomatology. — Aside  from  the  pressure  s\'mptoms,  hemorrhage, 
sometimes  so  great  as  to  threaten  life,  neuralgias,  and  disturbances 
of  respiration  are  the  most  prominent. 

Diagnosis. — The  chief  point  of  diagnosis  is  the  presence  of  a  tumor 
which  occupies  or  fills  the  pharynx  of  an  adolescent  male.  It  is  a 
pedunculated  mass  developing  from  the  vault  of  the  pharynx  and  fill- 
ing the  retronasal  fossa.  Its  smoothness  and  density  and  the  relative 
slowness  of  its  growth  distinguish  it  from  sarcoma.  The  malignant 
growths  usually  appear  later  in  life,  are  of  more  rapid  growth,  and 
are  of  softer  structure.  From  pharyngeal  polyps,  fibromas  are  distin- 
guished by  color,  density,  and  location,  the  microscopic  diagnosis  being 
less   reliable. 

Prognosis. — After  the  individual  has  attained  full  development  the 
tumor  frequentl}'  regresses  and  sometimes  disappears.  When  removed, 
cure  is  usually  permanent,  but  recurrence  may  take  place,  only  perhaps 
to  disappear  about  the  twenty-fifth  year.  Because  of  the  uncertainty 
in  diagnosis,  even  after  microscopic  examination,  the  prognosis  should 
alwaA's  be  guarded. 

Treatment.^  —  When  small  in  size,  pharyngeal  fibromas  have  been 
removed  by  means  of  a  snare  through  the  natural  passages,  but  it  is  a 
dangerous  procedure,  for  even  in  the  small  ones  the  blood  supply  ma}' 
be  very  abundant  and  lead  to  serious  after-hemorrhages.  The  large 
tumors  at  least  require  the  temporary-  resection  of  one  or  both  upper 
jaws,  with  or  without  the  ligation  of  one  or  both  external  carotids,  in 
order  that  the  hemorrhage  may  be  more  certainly  controlled.  Usually 
a  unilateral  operation  is  sufficient,  but  if  the  growth  is  very  large  both 
sides  should  be  exposed.  At  best,  the  operation  is  a  bloody  and  formid- 
able one,  and  ever}^  precaution  should  be  exercised  to  meet  every 
emergency. 

^  Custodis,  Beitr.  klin.  Chir.,  1905,  xlvii,  37. 


C'  II    \  V   I    i;  R     X  \  \' 
TUMORS   OF    INK   MOLTII    AM)    loNCill, 

General  Consideration.  runiors  of  rlu-  buccal  ca\ir\  and  its  con- 
ttius  nia\  tor  ct)n\cnicncc  he  considered  tojierlui".  (jlands  sinidar  in 
character  and  subject  to  like  diseases  are  distributed  throughout  the 
cavit}',  congenital  anomalies  affect  alike  various  portions  of  it,  and 
malignant  disease  beginning  in  one  part  extends  quickly  to  neighboring 
structures.     They  are  similar  in  structure  and  run  a  like  course. 

CYSTS    IN    THE    FLOOR    OF    THE    MOUTH 

Ranula.-  Ihese  c\sts  in  their  typical  form  are  derived  from  the 
outlet  ducts  of  the  sublingual  gland. ^  They  may  also  develop  from 
Xuhn's  glands,  which  lie  on  each  side  of  the  frenulum  toward  the  tip 
of  the  tongue,  and  from  the  incisive  glands  which  are  situated  at  the 
base  of  the  incisor  teeth.  Neumann-  has  classed  with  the  ranulas 
cystic  dilatations  of  Bochdalek's  glands.  True  cysts  occurring  in  these 
glands,  when  ver}'  large,  ma}'  be  present  m  the  floor  of  the  mouth,  but 
usually  the\'  are  found  at  the  base  of  the  tongue  alone,  and  for  this  reason 
are  best  classed  with  the  latter.  Ranulas  usually  occur  in  adults,  rarelx" 
in  children.  They  have  been  reported  as  occurring  congenitalh,  but 
confusion  with  cysts  of  the  th^roglossal  duct  in  these  instances  is  possible. 
The}'  arise  from  the  occlusion  of  the  outlet  duct  of  the  glands  by  chronic 
inflammation. 

Acute  ranula  ma\'  be  produced  by  sudden  occlusion,  as  by  stone. 
The  closure  of  the  duct  is  followed  b\"  the  retention  of  the  secretion, 
and,  in  addition  to  this,  exfoliation  of  the  lining  epithelium  and  exuda- 
tion from  the  surrounding  vessels  are  thought  to  compose  the  C3'stic 
contents.  With  the  growth  of  the  c}st  the  surrounding  tissues  are 
displaced  and  portions  of  the  cyst  ma\"  be  forced  between  the  fibers  of 
the  surrounding  muscles.  The  cystic  contents  rarel\'  contain  digestive 
ferments,  but  are  usualh'  clear  and  ropy,  seldom  brownish  or  blood}". 

When  the  tumors  are  small  the}'  are  situated  lateral  to  the  frenulum, 

'  \'on  Hippie,  Arch.  f.  klin.  Chir.,  1897,  h",  164. 
-Arch.  f.  klin.  Chir.,  1877,  xx,  825. 


316 


TUMORS  OF  THE  MOUTH  AND  TONGUE 


corresponding  to  the  situation  of  the  subhngual  gland,  and  bulge  the 
mucous  membrane  of  the  floor  of  the  mouth  (Fig.  225).  Wharton's 
duct  can  usuall}^  be  demonstrated  passing  directly  over  the  summit. 
When  they  become  larger  the}^  pass  the  median  hne,  and  the  frenulum 
above  them  may  cause  them  to  present  a  bilobed  appearance.  Occa- 
sionall}^  the}^  are  multilocular,  double,  or  even  multiple.  Accessory 
loculi  may  form  within  the  surrounding  muscle,  and  when  large  may 
extend    into    the    myohyoid    muscle    and    cause    a    prominence    beneath 


Fig.  22: 


Ranula  forming  a  lobulated  mass  under  the  tongue. 

the  chin,  or  in  the  region  of  the  submaxillary  gland  (Fig.  226).  Those 
forming  in  the  glands  of  Nuhn  are  situated  under  the  tip  of  the  tongue, 
and  those  forming  in  the  incisor  glands  are  beneath  the  frenulum 
immediately  beneath  the  bone.  The  last  two  are  rarer  than  those  of 
the  sublingual  gland. 

The  cysts  usually  have  a  grayish-blue  or  bluish-red  appearance, 
but  when,  as  rarely  happens,  acute  inflammation  takes  place,  they 
may  be  intensely  reddened.  They  are  soft,  fluctuating  to  the  touch, 
and  usually  relatively  movable. 


CYSTS   l\    Tin.    I  LOOK  or    I  III:    MOl   I'll 


wv 


Diagnosis.  Tluii  sitiKition  l)ciu:itli  rlu-  toii^iif,  |)r(jjecrinj;  into  rlu- 
suhlin^ual  spaii  .  iluii  Muisli  loloi,  ;in(l  i\  st ic  trtl  arc  usually  surticic-nt 
to  distiuj^^uisli  tlu-m.  W'luii  tin-  muious  iiunihiaiu-  c-()\criii^  riu-ui  is 
vasculai,  auuioina  iiuist  In-  thought  of,  Inir  a  globular  iiiconipicssihic 
tumor  is  distinctive  of  the-  cyst.  rh\  i()<;lossal  c\  sts  in  the  suprali\<)id 
ritiion,  wlun  projcctinu;  into  tin-  llooi  of  tin-  mouth,  mav  simulate 
laiuila.  I  suall\  in  laiuila  tin  re  is  a  history  of  a  hist  appearance 
heneath    the    tongue,   ami    there    is    no   attachment    to   the   h\()id    hone. 

Fig.  226 


Ranula  bulging  beneath  the  angle  of  the  jaw. 


as  in  the  thyroglossal  cysts.  Ranula  simulates  tumors  of  the  duct 
only  when  of  such  size  as  to  project  below  the  jaw.  This  condition 
has  seldom  been  observed.  An  inflamed  ranula  is  likeh'  to  be  mistaken 
for  inflammation  due  to  a  sialohth,  and  indeed  the  dividing  line  between 
the  two  conditions  ma}'  not  be  a  sharp  one. 

Treatment. — When  a  cyst  is  small,  excision  of  that  portion  of  the 
wall  which  projects  into  the  mouth  and  cauterization  of  the  remam- 
ing  portion  with  silver  nitrate  is  followed  by  a  cure.     Stitching  of  the 


318  TUMORS  OF   THE  MOUTH  AND  TONGUE 

cyst  wall  to  the  mucous  membrane  of  the  tongue  after  excision  of  the 
redundant  portion  and  cauterization  of  the  remaining  tissue  is  often 
followed  by  success.  Repeated  cauterization  during  the  healing  gives 
additional  security.  When  the  cyst  is  large,  excision  of  the  entire  sac 
should  be  practised.  This  may  be  done  through  the  mouth  or,  as 
V.  Hippie^  recommends,  by  an  incision  beneath  and  parallel  with  the 
jaw.  This  gives  a  better  view  of  the  field  of  operation  and  permits 
a  more  effective  hemostasis,  but  does  not  in  the  majority  of  instances 
avoid  an  opening  into  the  mouth.  Loose  packing  with  gauze  for  a 
number  of  days  must  be  done  after  the  use  of  either  method. 

Thyroglossal  Cysts. — The  imperfect  obliteration  of  the  fetal  thyro- 
glossal  duct  may  lead  to  the  formation  of  cystic  tumors  along  its  tract. 
The  part  most  commonly  affected  is  the  foramen  cecum  at  the  base 
of  the  tongue  and  immediately  above  the  hyoid  bone.  These  tumors 
are  ovoid,  bluish,  glistening  cysts  which  project  above  the  tongue. 
Usually,  when  first  observed,  they  are  as  large  as  a  hazelnut  or  a  hickoiy- 
nut.  Occasionall}^,  when  very  large,  or  arising  in  the  substance  of 
the  tongue,  they  ma}'  be  visible  beneath  the  tongue,  and  have  been 
classed  with  the  ranulas.  A  second  tumor  may  exist  in  the  tract  of 
the  duct;  these  are  particularly  likely  to  be  mistaken  for  ranula.  Often 
the  wall  of  the  cyst  contains  well-developed  thyroid  tissue,-  which  is 
frequently  very  vascular.  When  this  complication  exists,  the  color 
is  bluish  red  or  even  deep  red.  The  tumors  are  usually  soft,  elastic, 
and  painless.  When  small,  they  cause  no  inconvenience  unless  from 
hemorrhage.  When  they  become  larger,  they  may  exert  pressure  upon 
the  epiglottis  and  may  cause  cough  and  difficulty  in  swallowing.  Occa- 
sionally, repeated  hemorrhages  may  occur  before  the  tumor  is  dis- 
covered. The  blood,  because  of  its  unaltered  color  and  the  attending 
cough,  ma}^  be  ascribed  to  pulmonary  hemorrhage.  The  next  place 
of  predilection  is  immediately  above  the  hyoid  bone.  Tumors  which 
occur  here  have  the  same  characteristics  as  those  situated  at  the  base 
of  the  tongue,  but  the  overlying  skin  obscures  the  color. 

Diagnosis. — When  situated  at  the  base  of  the  tongue  their  globular 
form,  bluish  color,  and  situation  in  the  median  line  are  distinctive. 
When  situated  more  deepl}^,  so  that  their  bluish  color  is  obscured,  they 
may  be  confused  with  gummas.  The  latter  spring  up  more  rapidl}^, 
and  are  situated  laterally  to  the  median  line.  When  situated  below 
the  tongue  they  simulate  ranulas,  but  these  are  more  superficial  and 
bulge  to  one  side  of  the  frenulum.  Thyroglossal  cysts  below  the  chin 
(see  Tumors  of  the  Neck)  simulate  dermoids  and  lipomas,  but  they  are 

lArch.  f.  klin.  Chir.,  1897,  Iv,  164. 

'  Bernays,  St.  Louis  Med.  and  Surg.  Jour.,  1888,  iv,  201. 


os/s  i.\   ■/■///■:  I  LOOK  oi   I  III,    \ifji  III  :u\i 

mon-   ii,l()l"iiil;ii'   and   Iiss   tiiil\     moNahlc    th;in    t  hcsi,  and    an    ai  lathintiu 
to  {\\v  In  Old   honr  nia\    In-  made  out. 

Treatment.  I'or  those  sitnatcd  at  tin  Ikisc  ot  the  tonmic,  wlun  tlu-ir 
blue  color  indicatts  an  ahs«.iut-  ol  tinioid  tissue,  simple  excision  of 
rlie  redundant  tissue  with  caiitti  i/ation  ol  the  reinaiinnu  portion  of 
the  sac,  as  ad\ised  tor  lanulas,  nia\  In-  all  that  is  ie(|iiii((l.  ('omplete 
excision  is  to  hi'  piactisetl  wluii  this  iiKthod  tails;  hiii  this  measure 
is  contiaindicated  when  the  thyroid  tissue  al)o\'e  the  thyro^lossal  duct 
is  all  the  tunctioninji;  thyroid  tissue  the  patient  possesses.  Its  remo\al 
in  sucii  cases  would  he  followed  hy  cachexia  th\  ropi  i\a.'  I  sualh  , 
however,  rlu'  entire  growth  should  be  removed,  and  if  there  is  a  dis- 
position to  bleed,  remoN'al  is  imperative. 

It  simple  removal  ot  the  surface  of  the  c\sr  alone  is  iiucnded,  the 
operation  ma\'  be  undertaken  under  local  anesthesia,  Inir  it  the  urowth 
is  vascular,  a  general  anesthetic  should  be  employed  and  the  usual  pre- 
caution for  preventing  the  flowing  of  blood  into  the  trachea  should  be 
taken.  Fhis  operation  may  be  done  through  the  mouth  unless  the 
tumor  is  very  large,  wdien  an  incision  from  below  ma)'  be  advisable. 
The  lower  route  should  be  selected  if  there  are  secondary  tumors  below 
the  one  at  the  base  of  the  tongue.  1  raclieotomy  is  not  necessar\'  unless 
from  the  size  of  the  tumor  the  epiglottis  is  much  pressed  uj^on.  In 
that  event  the  method  of  Butlin  may  be  employed.  For  cysts  situated 
above  the  hyoid  bone  a  skin  incision  is  necessary,  and  sometimes  the 
h\'oid  bone  may  be  severed  with  advantage,  particularh'  if  the  c\st 
extends  back  of  it.  In  iistulas  resulting  from  ill-ad vised  treatment 
in  these  cysts,  the  entire  tract  must  be  carefully  excised,  always  under 
general  anesthetic. 

Dermoids. — Dermoid  C3'sts  are  sometimes  observed  under  the  tongue 
toward  the  base  situated  in  the  median  line  or  laterally.  The}'  form 
globular  tumors,  w'hich  are  smooth,  soft,  jelly-like,  and  sometimes 
fluctuating  to  the  touch.  The  skin  and  mucous  membrane  remain 
freeh'  movable  over  them.  The\"  are  painless  and  cause  disturbance 
only  wdien  from  their  size  they  embarrass  deglutition  or  speech.  I  hey 
project  into  the  mouth  and  limit  its  space  or  make  complete  closure 
of  the  mouth  impossible,  or  the}"  ma\'  project  outward  below  the  maxilla 
(see  Tumors  of  the  Neck).  The}'  frequently  have  a  fibrous  attachment 
on  the  inner  side  of  the  inferior  maxilla  above  the  attachment  of  the 
genioh\oid  muscle  or  to  the  bod}'  of  the  h}'oid  bone,  indicating  their 
origin  in  the  mesobranchial  fold.  The}'  are  lined  b}"  striated  epithelium 
which  contains  hair  follicles  and  sebaceous  glands,  and  are  filled  with 
a    granular   debris    which    ma\'     be    brownish    and    contain    cholestenn 

'  \  on  Chamisso  dt-  Boucourr,  Bt-irr.  /.  klin.  Chir.,  1S97,  \ix,  281. 


320  TUMORS  OF  THE  MOUTH  AND   TONGUE 

crystals.  These  tumors  may  be  observed  at  birth,  or  they  may  not  be 
noticed  until  an  advanced  period  of  life,  but  they  usually  manifest 
themselves  between  the  eighteenth  and  twenty-sixth  years. 

Diagnosis. — Their  yellowish  or  whitish  color,  usually  discernible 
through  the  mucous  membrane  of  the  mouth,  differentiates  them  from 
ranulas.  The  absence  of  lobulation  distinguishes  them  from  lipomas. 
If  the  strand  of  fibrous  attachment  to  the  body  of  the  hyoid  or  maxillary 
bone  is  made  out,  the  diagnosis  is  certain.  From  suprahyoid  cysts 
puncture  alone  will  differentiate.  Cold  abscesses  occasionally  develop 
in  glands  in  the  submental  region,  and  have  been  mistaken  for  dermoids. 
They  are  more  firmly  fixed  and  project  less  regularly  into  the  floor 
of  the  mouth.     In  case  of  doubt  an  exploratory  puncture  can  be  made. 

Treatment. — Excision  is  the  only  method  which  should  be  considered. 
When  small,  they  may  be  shelled  out  through  the  mouth,  but  when 
large,  they  are  better  attacked  through  a  skin  incision.  If  care  is  taken 
not  to  injure  the  floor  of  the  mouth,  the  wound  heals  primarily  and 
the  resulting  scar  is  insignificant.  The  size  of  the  cavity  remaining 
after  the  removal  of  the  tumor  may  be  lessened  by  buried  sutures,  which 
also  make  drainage  unnecessary.  When  the  tumor  is  removed  through 
the  floor  of  the  mouth,  the  wound  should  be  treated  as  an  open  one, 
using  a  temporary  packing  to  lessen  the  likelihood  of  infection  of  the 
cellular  tissue.  Local  anesthesia  is  sufficient  for  operation  by  either 
route. 

Lymph  Cysts. — Lymphatic  dilatations,  from  the  size  of  a  pea  to  that 
of  a  walnut,  may  occur  in  the  floor  of  the  mouth  and  in  the  tongue, 
but  usually  in  the  cheek  in  front  of  the  masseter.  These  tumors  are 
tense-walled  cysts,  with  endothelial  lining  and  without  perfect  encapsu- 
lation. They  may  simulate  adenomas  in  this  region.  If  they  cause 
inconvenience  from  their  size,  they  may  be  extirpated  entire  or  partially 
removed  and  the  remaining  portion  of  the  cyst  cauterized. 


MALIGNANT    TUMORS    OF    THE    MOUTH    AND    TONGUE 

Carcinomas  of  the  mouth  may  be  divided  into  those  of  the  tongue, 
those  of  the  floor  of  the  mouth,  and  those  of  the  buccal  mucous  mem- 
brane. They  have  much  in  common  and  run  a  similar  course,  yet 
their  great  practical  importance  makes  it  desirable  to  treat  them 
separately. 

Carcinoma  of  the  Tongue. — The  tongue  is  a  relatively  frequent  site 
for  carcinoma,  from  5  to  7  per  cent,  of  all  malignant  epithelial  growths 
being  found  here.  Males  are  much  more  frequently  affected  than 
females  in  the  proportion  of  about  8  or  10  to  i.     This  great  frequency 


M.ii.ic.s.isr  rr.MfjRs  or  the  moi  rii  ./\n  ro\(Jii-:         :',-2\ 

in  iiKilts  has  l>itii  thought  to  In-  dm-  to  tluir  nujie  general  addiction 
to  flu-  use  ot  akohol  and  tobacco.  In  carcniorna  of  the  tonj^ue  the 
iiiHiunce  ot  irritation  has  heen  tracetl  with  greater  exactness  than  in 
any  other  rej^ion  ot  the  hoil\  .  I  hi-  ina|oiit\  of  rnahj^nant  diseases  of 
the  tongue  occur  adjacent  to  the  roughened  edge  of  a  tooth  or  a  broken 
dental  plate.  1  his  association  is  so  common  that  attention  to  roughened 
objects  within  the  mouth  should  receive  correction  as  a  proph\  lactic 
measure  against  carcinoma  ot  the  tongue.  A  considerable  proportion 
of  lingual  carcinomas,  as  many  as  one  in  four  according  to  some  auth(jrs, 
are  preceded  by  leukoplakial  spots.  There  are  no  statistics  available, 
however,  relative  to  the  number  of  leukoplakial  areas  which  become 
carcinomatous. 

Fk;.  227 


Beginning  carcinoma  of  the  tongue,  showing  ulcer  developed  beside  a  papilloma. 

The  disease  begins  usuall\-,  as  in  case  of  the  lip,  as  an  ulcer  f  Fig.  227), 
or  a  leukoplakial  patch  (Figs.  228,  229,  and  230).  The  transition  into 
carcinoma  is  characterized  b\'  an  induration  about  the  base,  which  is 
harder  than  an  inflammator\'  exudate  and  which  spreads  beyond  the 
contines  of  the  epithelial  defect.  The  papillomas  of  the  tongue  are 
especially  prone  to  intiltrate  the  base.  Leukoplakial  areas  undergo 
changes  much  more  slowly,  \ears  being  sometimes  required  for  them 
to  reach  a  malignant  stage.  Each  of  these  types  when  full}-  developed 
has  edges  which  are  hard  to  the  touch,  are  usually  raised  above  the  sur- 
rounding surface  of  the  tongue,  and  have  enclosed  within  their  walls 
an  angry  granular  surface  which  bleeds  easih'  on  touch. 

As  in  most  carcinomas,  "cancer  plugs"  can  often  be  seen  about  the 
border  of  the  ulcer,  and  can  be  forced  out  by  firm  pressure.  The  base 
21 


322 


TUMORS  OF  THE  MOUTH  AND   TONGUE 
Fig.  228 


Leukoplakia  of  the  tongue. 
Fig.  229 


'<7-  '   't-  /- 


)      / 


U:, 


X  y\i 


iiJ 


J        V'--   c^ 


Leukoplasia,  benign  stage. 


\i  ii.h.\  i\r  77  MORS  or  Tin:  moi  rii    /\/>  ioma  i-  .lm 

(>t  the  iilrci  m.i\  tiiiiL^.iti  .iiul  |iiii(liii(  .1  l.ii^i-  mass  \slm"li  projects  a 
(.■oiisulii  .ihic  ilisi.iiur  .il)i)\(  il)(  Ml  1 1  ( Hindi  iiL!  siiil.icc  i)t  tlic  roiijiut*. 
Mir  iii.iss  is  iisii.ill\  liim  .iiul  tii.iMc.  Molt  i.iicK,  ilic  ca  ifinonia 
iit\rlops  within  ilu-  siihst  .1  nrr  ot  the  tontiut-,  lta\in^  tin-  surface  tor  a 
turn  unhiokiii.  ( iiaciual!\  ,  lio\\t\ii,  rlie  suiface  is  encToached  upon 
and  an  iiUfi  results,  diH-eiiii<;  tin  11  m  no  wise  from  those  which  befiiii 
oii!j,inall\  as  ulcers.  I  siialh'  the  caicmoiiia  picsenfs  itscH  as  a  ciicum- 
scrdnd  iilcei,  Inn  occasionalK  tlu-re  is  a  dilliisc  inhhiaiion  iiuoKin;^, 
hom  the  luij^innini:,  a  consuleiahle  area  ot  the  tonji;ue.  I  he  edue  ot 
the  tongue  IS  h\  fai  the  most  tie(iuent  site  because  of  the  exposure  ot" 
this  jxirt  to  irritation.  I  hose  arismu  trom  leukoplakial  spots,  however, 
are  seen  most  tii-tpienth    m   the  dorsum. 

Viv..  230 


Leukoplakia,  beginning  malignancy. 

Pain  IS  usuall)'  an  early  symptom.  Contact  with  the  teeth  or  \Mrh 
irritating  articles  ot  food  causes  pain  as  soon  as  the  epithelium  is  lost. 
Radiating  pains  begin  as  soon  as  infiltration  is  at  all  marked.  The 
pain  IS  referred  to  the  cheek  or  jaw,  and,  when  the  tumor  is  situated 
on  the  side  of  the  tongue,  toward  the  ear  or  mastoid  region. 

The  extension  of  the  disease  is  usualh'  rapid.  The  cause  of  this  has 
been  sought  in  the  loose  arrangement  of  the  structure  of  the  tongue, 
the  abundant  blood  supply,  and  the  number  and  size  of  the  l\"mph 
channels.  In  some  instances  the  extension  is  excessiveh'  rapid,  the 
entire  tongue,  the  floor  of  the  mouth,  and  tissues  of  tiie  neck  being 
(juickly  imadetl  b\'  the  epithelial  cells  accompanied  b\'  an  extensive 
round-celled  infiltration.  So  rapid  is  this  process  that  in  the  course 
of  weeks  the  tongue  is  converted  into  a  solid,  immovable  mass,  making 
deglutition  difficult  or  impossible  (Fig.  231).     This  type  is  most  often 


324 


TUMORS  OF   THE  MOUTH  AND   TONGUE 


seen  in  persons  under  forty  A^ears  of  age  in  whom  a  diagnostic  section 
or  a  partial  operation  has  been  performed.  Slowly  growing  carcinomas 
are  rarely  found  on  the  tongue. 

The  lymph  gland  metastasis  is,  as  a  rule,  very  early  and  has  already 
taken  place  when  the  surgeon  is  consulted,  notwithstanding  the  exposed 
situation  of  the  disease  and  the  consequent  tendency  of  the  patient 
to  seek  advice  early.     The  order  in  which  the  glands  are  involved  is 


Fig.  231 


Rapidly  growing  carcinoma  of  the  tongue,  involving  also  the  floor  of  the  mouth. 

not  constant.  The  submaxillary  glands,  because  of  the  more  frequent 
location  of  the  growth  on  the  lateral  surface  of  the  tongue,  are  usually 
the  first  invaded.  When  the  tip  is  the  seat  of  the  disease  the  submental 
glands  may  be  the  first  affected.  When  the  growth  is  near  the  base 
the  deep  cervical  glands  may  be  the  first  affected.  It  must  be  assumed 
that  all  these  glands  are  implicated  in  any  given  case  of  carcmoma 
of  the  tongue.     Not  alone  are  those  on  the  diseased  side  affected,  but 


M.n.i(.\  i\T  ri  MORS  (ii  Tin    moi  tii   i\h  7n\(,rr.         :i2.') 

because  ot  the  iich  l\  inphatic  anastomosis  at  tlu  root  ot  the  ton};iie 
the  opposite  side  is  (juite  as  hkel\  to  he  invaded.  Indeed,  the  glands 
of  the  opposite  side  may  he  the  Hist  or  even  the  only  ones  to  be  aftected. 

When  s\  stemic  cUssemination  takes  place,  the  liver  is  the  most  fre- 
(juent  site  of  metastasis.  This  may  occur  before  the  regional  l\  mph 
j^lands  are  diseased,  and  indeed  before  the  primar\-  tumor  is  discovered, 
though  this  is  ran-.  I  his  is  particularly  true  in  those  which  occur  at 
the  base  of  the  tongue  or  in  the  Hoor  of  the  mouth.  I  his  should  be 
remembered  in  obscure  hepatic  disease. 

Diagnosis.  —  It  is  the  diagnosis  of  tongue  carcinoma  that  v.  Bergmann 
was  wont  to  dilate  upon  in  discussing  the  differential  diagnosis  of  carci- 
noma, syphilis,  and  tuberculosis.  Syphilis  is  sometimes  multiple,  is 
situated  more  often  on  the  dorsum  of  the  tongue,  begins  deep  in  the 
substance  of  the  organ  and  not  near  a  broken  tooth,  and  the  lesion 
is  more  nearly  spherical,  more  circumscribed,  and,  above  all,  is  not 
as  dense  to  the  touch  as  carcinoma.  Lsuall\-  there  are  other  signs  of 
svphilis.  Tuberculosis  of  the  tongue  is  rare.  It  may  occur  on  any 
part;  the  ulcer  is  usually  superficial,  the  edges  are  soft  and  under- 
mined. Sometimes,  however,  the  tuberculous  ulcer  ma\-  form  a  large 
fungous  mass,  which  resembles  very  closely  the  fungating  carcinoma. 
There  is  usually  tuberculosis  elsewhere  in  the  body,  particularly  in 
the  lungs,  which  would  suggest  the  nature  of  the  tongue  lesion.  Lung 
metastasis  from  carcinoma  may  be  mistaken  for  a  tuberculous  pro- 
cess. Careful  physical  examination,  together  with  examination  of  the 
sputum,  will  distinguish  the  nature  of  the  lung  alfection. 

In  the  rapidh'  growing  type  of  carcinoma,  a  phlegmonous  process 
mav  be  thought  of,  but  the  former  is  less  acute,  and  the  density  and 
nodulation  always  discoverable  in  some  part  of  the  tumor  are  distinc- 
tive of  the  neoplasm.  Besides,  there  is  usually  the  history  of  some 
primarr  lesion  which  has  been  subjected  to  ill-advised  treatment.  The 
primary  lesion  of  syphilis  with  extensive  gland  disease  may  simulate 
this  type  of  carcinoma  very  closely,  but  a  search  for  the  dense  nodula- 
tions  of  carcinoma  and  the  evidence  of  syphilis  elsewhere  in  the  body 
will  permit  a  diagnosis. 

It  is  in  the  mouth  that  surgeons  most  often  desire  the  aid  ot  the 
microscope  for  diagnosis.  It  is  here  also  that  exploratory  incision  is 
so  likely  to  provoke  mischief  because  of  its  disposition  to  increase  the 
likelihood  of  metastasis.  Every  means  should  be  employed  to  arrive 
at  a  diagnosis  before  removing  a  section  for  examination.  Inoculation 
tests  for  tuberculosis  and  the  therapeutic  or  serum  tests  for  syphilis 
usually  allow  us  to  arrive  at  a  diagnosis  by  exclusion.  Moreover,  carci- 
noma, when  present,  is  usually  only  too  clearly  such.  \\  hen  the  diagnosis 
is  in  doubt,  in  the  vast  majority  of  cases,  the  disease  is  not  carcinoma, 


32(3  TUMORS  OF   THE  MOUTH  AND   TONGUE 

but   definite   proof  of  this   assumption   is   best   brought   to   the   patient 
by  the  cure  of  the  lesion  if  it  is  other  than  carcinoma. 

Treatment. — Local  treatment  is  never  permissible.  When  the  lesion 
is  small,  an  excision  of  a  wedge,  ij/^  centimeters  beyond  the  border  of 
the  tumor,  ma}^  be  permitted.  If  at  all  diffuse  or  extensive,  a  lateral 
half  of  the  tongue  should  be  sacrificed.  Local  return  is  more  common 
than  recurrence  at  distant  lymph  glands,  and  as  much  tissue  as  possible 
in  the  region  of  the  growth  should  be  removed.  When  removed  with 
the  cautery,  recurrence  is  less  likely  than  when  a  scalpel  is  employed. 

In  either  case  the  adjacent  lymphatics,  together  with  the  salivarj^ 
glands,  should  be  removed  in  all  instances.  The  sternomastoid  glands 
receive  the  lymphatics  from  the  tongue.  These  glands  are  situated 
beneath  the  sternomastoid  muscle  upon  and  behind  the  internal  jugular 
vein.  Their  complete  removal  is  best  assured  by  removing  the  vein, 
together  with  the  surrounding  tissue  after  Crile's  method.  The  neces- 
sary exposure  can  be  secured  by  adding  to  the  Kocher  incision  one 
extending  down  the  anterior  borders  of  the  sternomastoid  muscle  to 
the  clavicle,  as  recommended  by  Plummer  for  the  removal  of  tubercu- 
lous lymph  glands.  If  the  growth  is  well  confined  to  a  lateral  half  of 
the  tongue  and  is  in  its  incipiency,  such  an  operation  may  be  regarded 
as  a  complete  one.  If  the  midline  is  affected,  or  if  the  tumor  is  on  one 
border  and  has  existed  for  some  time,  or  is  of  rapid  growth,  both  sides 
of  the  neck,  at  separate  sittings  if  need  be,  should  be  subjected  to  similar 
treatment.  If  the  glands  are  palpably  involved  the  entire  lymphatic 
apparatus  should  be  removed.  The  method  of  removal  is  unimportant, 
but  to  the  incision  of  Kocher  the  temporar\'  resection  of  the  jaw  should 
be  added.  When  the  malignant  process  has  extended  to  the  floor  of  the 
mouth,  a  permanent  cure,  regardless  of  the  extent  of  the  operation, 
is  hardly  to  be  hoped  for. 

Carcinoma  of  the  Floor  of  the  Mouth. — Primary  carcinomas  are 
observed  in  the  floor  of  the  mouth  less  frequently  than  on  the  tongue. 
They  begin  as  fissures  and  ulcers  with  gradually  extending  borders, 
and  are  prone  to  infiltrate  quickly  the  loose  connective  tissue  of  the 
mouth.  Their  exposed  situation  invites  secondar}^  bacterial  infection. 
Metastatic  processes  are  likely  to  occur  early  in  the  regional  lymphatics, 
which  may  comprise  any  of  the  Ij^mph  gland  group  of  the  neck,  and 
the}'  are  especialh"  prone  to  occur  in  the  viscera.  The  liver  is  most 
frequently  involved,  and  in  case  of  obscure  tumors  of  the  liver  or  hepatic 
enlargement  the  mouth  should  be  examined  for  possible  malignanc3^ 
The  growth  primarily  causing  such  mischief  may  be  so  small  as  not 
to  have  attracted  the  patient's  attention. 

Diagnosis. — The  indurated  ulcer,  the  presence  of  carcinoma  nests, 
and  enlarged  hard   glands  are  distinctive.     Frequently,  however,  com- 


() 


.1/. //,/(,  \./.\y  11  MORS  (Ji   riii:   moi  rii    i\n  iDM.ri-:  wr, 

plications  iiulu.iiini;  ;i  simpK-  inHamnKiioi  \  aHiiiion  iiia\  (thsiint- 
rlu-  pu-tiiu.  S\pliilitu'  Ksions  ina\  siimilaic  it  ami  tin-  iapiclir\  of  tlu- 
ina  lii:,iiani  pi  orcss  m.i  \  ;ultl  I  o  l  he  i.(Hif  iimi  )n  .  ()thti  cv  uitiuc  of  s\'phili.s 
ma\,  howiNii,  usiialU  hi  iliscoNtiid.  Atiiic  pliici^monoiis  processes 
I  l.iulw  ii^'s  anjiinal  nia\  Imin  a  tlcnsc  tuiiioi,  luit  tin  i;rcatii  jiia\"it\' 
of  tlu-  scpnc  |")i"()ccss  in  Muh  casi-s  (lisnii^iinslus  iluni  hom  taicinonia 
i'oni|i|ica  ti-il  li\  cHJiulai  intiriion.  In  ail  in()in\  losis,  xsjicn  the  Hoor 
t  rlu-  moiitli  IS  imacltil,  t  lu-  cnla  i  i^inuni  is  Jess  dense  than  carcinoma 
and  rlu'  siiitaci'  is  loiindci.  In  this  coimriN'  actmonncosis,  paitiCu- 
lail\     in    tins    location,    is   ixccssin  il\     lair. 

Treatment.  Wlun  tin  timioi  is  small,  tin-  Hooi  ot  tin  month,  with 
hoiderins2;  lymph  glands,  ma\  be  excised,  pieferahl\-  with  the  caiitei\  ; 
withont,  ho\\e\er,  any  considerable  hope  of  success.  W  hen  the  Hoor 
ot  the  month  is  at  all  extensively  affected,  the  <i;ro\vth  should  be  regarded 
as  inoperable  even  when  the  remoxal  of  the  entire  mass  is  technicaih' 
possible.  Experience  has  |")ro\ed  that  \isceral  metastasis  is  hastened 
by   such   attempts. 

Carcinoma  of  the  Buccal  Mucous  Membrane.  The  mucous  mem- 
brane lining  the  cheek  is  frequentl\-  the  site  of  carcinomas.  Here,  as 
in  the  case  of  the  lip  and  tongue,  the  initial  lesion  ma\'  be  a  papilloma, 
an  irritated  spot,  or  a  leukoplakial  area,  though  the  last  is  rareh'  found 
on  the  cheek.  1  he  border  of  the  lesion  becomes  indurated  and  an  ulcer 
or  fungous  mass  is  formed  which  extends  through  the  cheek  and  becomes 
apparent  on  the  outside. 

Diagnosis. — An  ulcer  within  the  cheek  having  a  dense,  toughened 
edge  adjacent  to  a  broken  tooth  is  almost  certainly  carcinomatous. 
Tuberculous  lesions  ma\-  be  distinguished  from  carcinoma  b\'  their 
soft  overhanging  edges.     Actinomycosis  may  imitate  carcinoma  closeh'. 

Treatment. — Excision  of  the  area,  together  with  the  glands  which 
drain  it,  should  be  practised.  The  requirements  in  general  are  the 
same   as   for  carcinoma   of  the   tongue. 

Sarcoma  of  the  Tongue. — Sarcoma  is  an  infrecjuent  tumor  of  the 
tongue,  Marion'  being  able  to  collect  but  27  cases  from  the  literature. 
All  types,  round-celled,  spindle-celled,  and  even  giant-celled  tumors, 
have  been  noted.  Males  and  females  are  equall\-  affected,  and  one- 
half  the  cases  reported  have  been  in  childhood  and  adolescence.  1  Opo- 
graphically,  two  varieties  have  been  described — those  occurring  within 
the  muscle,  the  interstitial,'-  and  those  situated  immediatel}'  below  the 
mucosa,   the  submucous.      Clinically,   there  seems   to  be  no   important 

'  Re\-.  de  chir..  iScjj,  wii,  igi,  574,  668. 

-  K.  K.  Dunham,  Amcr.  Jour.  Med.  Sci.,  1895.  ex,  2^9. 


328  TUMORS  OF  THE  MOUTH  AND  TONGUE 

difference  in  the  two  types.  Both  types  cause  trouble  by  their  size 
only.     Bloodgood^  reports  a  sarcoma  of  the  floor  of  the  mouth. 

Diagnosis. — Syphihs  has  frequently  been  mistaken  for  sarcoma,  owing 
to  the  circumscribed  growth,  soft  consistency,  and  relatively  slow 
course  of  lingual  gumma.  The  disposition  to  stalk  formation  or  to 
infiltration  in  some  of  the  reported  cases  of  syphilis  pointed  also  to 
sarcoma.  A  number  of  the  sarcomas  have  been  noted  in  early  life 
before  the  syphilitic  lesion  would  be  expected.  Carcinomas  which 
develop  beneath  the  mucosa  may  be  confusing  before  the  stage  of  ulcera- 
tion. In  these  cases,  however,  although  the  mucosa  be  intact,  it  is 
adherent  to  the  tumor,  while  in  sarcoma  the  mucosa  is  free  for  a  long 
time.  The  lymphangiomas  when  circumscribed  and  so  deeply  seated 
that  the  vesicles  are  not  noticed  upon  the  surface  may  cause  confusion. 
Indeed,  some  of  the  cases  reported  in  the  literature  as  sarcoma  seem 
to  belong  to  this  group.  The  nodular  surface  of  the  lymphatic  tumor, 
even  when  deep  seated,  should  on  palpation  prevent  confusion.  The 
great  rarity  of  sarcoma,  particularh"  in  the  adult  male,  should  lessen 
the  number  of  errors  in  diagnosis.  Some  of  the  hyperplastic  tubercu- 
lous processes  may  resemble  sarcoma  very  closely.  Even  careful  micro- 
scopic examination  may  clear  up  the  problem  with  difficulty.  In  one 
case  examined  in  my  laboratory  it  was  only  after  a  number  of  blocks 
were  examined  that  definite  evidence  of  tuberculosis  was  established. 
Tuberculous  lesions  elsewhere,  chiefly  pulmonary,  are  the  clinical 
guiding  signs  in  these  cases. 

Treatment. — Wide  local  excision  is  the  important  factor.  It  is  impos- 
sible from  the  available  data  to  establish  a  general  rule  in  practice. 
The    results    after   operation    are    more   favorable    than    for   carcinoma. 


BENIGN   TUMORS   OF   THE   MOUTH   AND   TONGUE 

Lymphangioma. — These  tumors  usually  occur  in  the  young,  and  are 
sometimes  associated  with  congenital  lymph  cysts  of  the  neck.^  These 
tumors  have  followed  operations  upon  the  jaw  and  division  of  the 
frenulum.^  They  appear  as  small  clear  vesicles  (Fig.  232)  on  some 
part  of  the  tongue.  They  are  thickly  set  and  for  the  most  part  buried 
in  the  substance  of  the  tongue.  They  may  sometimes  be  red  from 
hemorrhage;  when  coagulation  occurs,  they  become  bluish  black.  Inflam- 
mation  of  the  connective   tissue   among  the  vesicles   ma}^  cause  it  to 

^  Johns  Hopkins  Hosp.  Bull.,  1894,  v,  120. 
^  Maas,  Arch.  f.  klin.  Chir.,  1872,  xiii,  413. 
^  J.  Dollinger,  Arch.  f.  klin.  Chir.,  1878,  xxii,  701. 


HEMC.S  TL  MORS  Ol    Till:    MOLT  J/   .l.\l)  TO.\ULE  'A'2U 

become  redder  than  normal.  I  hese  vesicles  may,  when  Hrst  observed, 
be  tew  ill  number.  From  time  to  time  acute  exacerbations  of  the 
inHammar()r\  process  take  place,  during  which  the  entire  tonj^ue  be- 
comes inrianucl,  edematous,  and  |Kiinful.  After  a  week  or  two  ot  this 
condition,  the  acute  process  ^raduall\  subsides,  but  the  orj^an  remains 
permanenth'  larger  than  before  the  attack.  In  this  respect  the  disease 
resembles  elephantiasis.  \\  irh  successive  attacks  the  tonj:;ue  becomes 
enlarj^ed  until  the  ca\it\  ol  the  mouth  is  no  lonj^er  able  to  contain 
it.  Alter  it  protrudes  from  the  mouth  it  is  subject  to  injury,  and,  in 
addition,  secondar\-  processes,  such  as  fissure,  may  occur. 

Fig.  232 


Lymphangioma  of  the  tongue. 

To  the  touch  the  entire  diseased  area  feels  dense,  with  yet  denser 
spots  corresponding  to  the  individual  nodules.  When  first  observed, 
the  tumor  may  be  superficial,  but  after  a  time  the  entire  thickness  of 
the  tongue  is  involved.  Between  the  vesicles  13'mphoid  tissue  some- 
times appears,  and  is  said  at  times  to  suggest  sarcoma.  The  floor  of 
the  mouth  may  be  independently'  the  seat  of  lymphangiomas,  or  these 
tumors  may  be  associated  with  lymphatic  tumors  of  the  neck.  They, 
as  also  the  lymph  cysts  of  the  neck,  are  more  likeh'  to  be  present  at 
birth  than  are  progressive  lesions  of  the  tongue. 


530 


TUMORS  OF   THE  MOUTH  AND   TOXGUE 


Diagnosis. — The  history  of  the  onset,  the  vesicles,  and  the  periods 
of  exacerbation  make  the  disease  unmistakable,  even  when  small  and 
relatively  circumscribed.  It  bears  no  resemblance  to  the  parenchym- 
atous hj^pertrophy  (Fig.  233)  with  which  it  is  usually  classified.  In 
that  condition  the  muscle  cells  are  increased  in  size  and  number,  and 
form   a   uniform   enlargement  without  the  appearance  of  the  vascular 

Fig.  233 


Parench3'matous  hv'pertropliy  of  the  tongue. 

nodules.  However,  when  repeated  inflammator}'  attacks  have  occurred 
this  mterstitial  reaction  ma^'  cause  the  muscle  fibers  to  appear  promi- 
nently; the  differentiation  is  then  dependent  upon  the  discover}^  of 
the  vesicles.  Many  authors  describe  these  under  the  head  of  Ivmph- 
angiomatous  macroglossia.  A  combination  of  the  lymphatic  and 
muscular  type  of  macroglossia  may  occur. ^ 

1  Wright,  Med.  Rec,  New  York,  1885,  xxvii,  537. 


R.I  HI:    n  MOKS   (Jl     rill:    TOM. IE  SM 

Treatment.  It  is  of  tin-  utmost  iiiiportinu'e  that  the  tit-atment  l)f 
iiistitutcil  caih  lucausi-  of  tin-  disposition  of  tlu-  disease  to  extend. 
l"!\cision  in  the  hiu-  ot  hialth\  tissiu'  is  thi-  onK  tieaimciit  attiiuled 
h\  suece.ss.  \\  lien  tlie  area  iinoKicI  is  small,  this  [>Ian  ean  he  earned 
out  without  detormit)  resulting.  L  iitortunatel\  ,  however,  the  diaj^- 
nosis  is  usuall\  not  made  until  so  large  an  area  is  invoK'ed  that  it  would 
necissitate  the  lemoxai  ot  the-  major  portion  ot  the  tongue.  When 
this  state  is  reached,  it  is  as  well  to  allow  the  organ  to  remain  until 
from   its   si/e   it   demands    iemo\al. 

Hemangiomas.  I  In-  tongue  is  not  uncommonly  the  seat  ot  angicMiias. 
Racemose  aneui\sms  ha\e  heen  obser\ed,  hut  the  usual  torm  is  the 
arteriovenous.  K.xtension  ot  capillar)  ne\i  trom  the  lips  upon  the 
tongue  is  occasionally   noted. 

Diagnosis.  I  he  diagnosis  ot  none  ot  these  types  sh(nild  cause  ditH- 
cultw  I'he  color,  the  pulsation,  or  the  reduction  when  compressed 
with  siihse(]uent  retilling  are  characteristic. 

Treatment.  In  the  racemose  type  the  supplying  vessels  should  be 
ligated.  In  the  arteriovenous  type,  if  small,  excision  with  (^r  without 
a  preliminar\'  ligation  ot  the  lingual  arteries  is  the  treatment  ot  choice. 
In  the  nevoid  t\'pe  electrolysis  is  the  method  ot  election. 


RARE    TUMORS    OF    THE    TONGUE 

Lipomas. — Occasionalh"  small  lipomas  appear  on  the  surface  of  the 
tongue  or  within  its  substance,  or  rarely  in  the  floor  ot  the  mouth. 
When  near  the  surface,  the  yellow'ish  appearance  characteristic  of  these 
tumors  ma\'  be  seen.  To  the  touch  the}'  are  sott  and  non-resistant. 
When  the\'  occur  in  the  floor  of  the  mouth  their  lobulation  differentiates 
them  from  dermoids,  but  in  some  cases,  puncture  ma}'  be  necessary  tor 
a  decision.  When  they  become  large  enough  to  cause  annoyance,  they 
ma\'  be  removed.  Those  situated  on  the  floor  ot  the  mouth  should 
be  removed  through  a  submaxillar\'  incision,  in  order  to  avoid  opening 
into  the    mouth    cavity. 

Fibroma. — These  tumors,  like  the  preceding,  are  sometimes  tound 
upon  or  within  the  substance  of  the  tongue.  They  are  frequently 
pediculated.  The\'  ma\'  form  dense  tumors,  and  when  located  m  the 
substance  of  the  tongue  may  cause  confusion  with  gummas,  c^'sts, 
and  even  carcinoma.  Their  dense  citcumscribed  character  should 
distinguish    them.      They    ma}-    be    removed    if  the\"    cause   annoyance. 

Gummas. — Gummas  ma}'  occur  in  an}'  part  ot  the  tongue.  1  he}' 
are  usualh'  the  result  of  acquired  s}philis,  and  usuall}'  occur  a  number 
of  \'ears  after  the  beginning  of  the  disease.     The\'  torm  nodules  var\"- 


332  TUMORS  OF  THE  MOUTH  AND  TONGUE 

ing  in  size  from  a  pea  to  a  walnut,  and  may  be  multiple.  They  are 
usually  smooth,  and  the  mucous  membrane  over  them  is  usually  un- 
changed, but  may  be  reddened.  The  consistency  may  be  very  dense, 
but  when  they  approach  ulceration  ma}^  become  soft  and  fluctuating. 
They  may  exist  for  a  period  of  years  without  showing  any  disposition 
to  ulcerate. 

They  differ  from  carcinoma  in  their  smoothness,  their  intact  surface, 
their  less  density,  their  usual  occurrence  in  early  life  (twenty-five  to 
thirty-five),  and  in  the  fact  that  no  chronic  irritant,  such  as  a  broken 
tooth,  may  be  found.  In  addition,  there  is  evidence  of  syphiHs  else- 
where. They  resemble  sarcoma  in  situation  and  form.  The  therapeutic 
test  should  be  appHed  in  cases  of  doubt. 


C  II  A  V   I    K  k     X  X  \    I 

llMokS  Ol-    rilK   lAWS,  GUMS,  TEE'IIL  I'KR  lOSTEUM, 

AND    BONK 

General  Conception.  1  uniois  of  the  ^ums  and  jaws  and  those  resuit- 
in<i  troiii  anomalous  development  of  the  teeth  are  closely  associated 
in  man\-  of  their  clinical  s\mptoms,  and  ma\'  profitably  be  considered 
together.  Aside  from  carcinoma  and  epulides.  the\  are,  on  the  whole, 
infrequent  tumors. 


TUMORS    OF    THE    GUMS 

Epulis. — Under  this  term  has  been  described  a  variety  of  tumors 
springing  from  the  alveolar  processes  of  the  jaw.  It  is  properl\'  re- 
served, however,  for  tumors,  sarcomatous  in  character,  which  spring 
from  the  alveolar  periosteum.  Tumors  springing  from  the  myeloid 
portion  of  the  bone,  and  afterward  breaking  through  the  surface,  have 
in  the  past  been  classed  with  the  epulides,  but  because  of  then-  chnical 
differences  these  are  best  described  as  sarcomas  of  the  jaws.  An  effort 
has  been  made  to  divide  the  epulides,  according  to  their  structural 
characteristics,  into  fibrous  and  sarcomatous  types.  Distinctly-  fibrous 
and  equalh-  distinctly  sarcomatous  tumors  are  observed,  but  there  are 
transitional  types  which  represent  very  cellular  fibromas  and  cannot 
be  distinguished  from  fibrosarcomas.  The  rate  ol  growth  is  as  important 
as  microscopic  structure  in  determining  their  nature. 

Pathology. — Epulides  are  localized  tumors  springing  from  the  vascular 
layer  of  the  alveolar  periosteum.  In  their  early  growth  they  carry  before 
them  the  fibrous  la^er  of  this  membrane,  but  in  their  later  growth 
they  invade  this  layer,  together  with  the  surrounding  fibrous  tissue. 
The  mucous  membrane  remains  permanenth-  or  at  least  for  a  long 
time  intact.  The\-  appear  upon  the  alveolar  border  or  between  the 
teeth  as  circumscribed  nodules  (Fig.  234),  varying  from  the  size  of  a 
pea  to  that  of  an  apple,  and  are  sometimes  distinctly  stalked.  The  dis- 
turbance the\-  cause  is  purel}-  mechanical.  They  cover  up  the  teeth  and 
thus  interfere  with  mastication.  This  exposes  them  to  injury,  which, 
with  the  hemorrhage  and  the  subsequent  ulceration,  is  the  patient's 
chief  complaint;  but,  on    the   whole,   the  disposition    to    ulceration    is 


334      TUMORS  Of  THE  JAWS,   GUMS,  TEETH,  PERIOSTEUM,  AND  BONE 


Fibrous  epulis. 


surprising!}'  slight  considering  the  traumatism  to  which  their  situation 
naturally  subjects  them.     Those  tumors  arising  from  the  roots  of  the 

teeth    may    gam   some    size   before 
^-^4  they     project     from     the    alveolar 

border.  The}^  are  frequently  at- 
tended b}'  pam  and  loosening  of 
the  teeth. 

Types. — Two  types  ma}'  be  rec- 
ognized— the  hard  or  fibrous,  and 
the  soft  sarcomatous.  The  former 
IS  made  up  of  fibrous  tissue  in 
var3'ing  proportions.  Such  tumors 
are  slowly  growing,  whitish  in 
color,  and  contain  little  blood. 
The  latter  type  has,  in  addition  to  fibrous  tissue,  giant  cells  which  are 
probably  of  m3^elogenous  origin.  This  tjpe  is  characterized  by  a 
peculiar  reddish-brown  color,  usually  easih'  perceptible  through  the 
intact  mucous  membrane  and  resembling  closel}'  that  of  striated  muscle. 
The  structure  varies  from  pure  fibromas  to  typical  sarcoma.  In 
the  majority  careful  search  will  reveal  giant  cells.  An  intermediate 
tj^pe  is  made  up  of  ver}^  cellular  connective  tissue.  This  structure  is 
particularly  apt  to  persist  in  recurrences.  The  giant  cells  are  those 
characteristic  of  m\'eloid  sarcoma;  the  alveolar  process  is  the  only  part 
of  the  bod^'  where  giant  cells  spring  from  periosteum  (v.  Bergmann). 
Diagnosis. — The  diagnosis  is  made  from  their  topographical  relation. 
The  intact  mucosa  covering  them  distinguishes  epulides  from  the  granu- 
lation processes  produced  by  decayed  teeth  or  necrosed  bone.  They 
are  distinguished  from  sarcoma  of  a  more  malignant  type  by  their 
slow  growth  and  by  their  slight  disposition  to  invade  surrounding 
tissue.  Carcinomas  of  the  gums  grow  much  more  rapidly  and  are 
primarily  ulcerative,  and  even  when  they  become  fungoid,  the  primary 
ulcerative  character  of  the  process  is  usually  manifest. 

Treatment. — Epulides  are  the  least  malignant  tumor  to  which  the 
term  sarcoma  has  been  applied,  and  are  cured  by  complete  local  re- 
moval. If  recurrence  takes  place,  the  growth  is  for  a  long  time  local. 
Small  tumors  which  develop  at  the  alveolar  border  and  do  not  involve 
tooth  sockets  are  often  cured  by  simple  excision  of  the  tumor,  includ- 
ing the  periosteum.  Care  must  be  taken  that  all  the  periosteum  of 
the  alveolar  process  between  the  teeth  is  removed.  In  small  tumors, 
whether  sarcomatous  or  not,  a  cure  results  by  these  means  without 
removal  of  teeth. 

Conservative  operations  are  fortunatel}'  most  often  possible  in  young 
unmarried  women,  in  whom  cosmetic  results  are  ver}'  important,  because 


■//  \i(Jks  or  rill.  (.1  \is  :y.io 

in  rlu-ni  rlu-  slowly  j;i()\Mn^  hhioiis  r\  [u-  is  most  loiiimoii.  During 
prf<in;iiu\  ilu-  ilisjiosirion  ro  nciir  is  nri;irii  th:in  ;it  orlui  tiiiu-s,  a 
point  ro  In-  kipt  in  niiiul  iii  ilu  stUcrion  ot  rlu-  t  \  p(-  ot  <)|>i!;ition.  More 
extensive  tuniois,  piirtuuhii  l\  \slu-n  :uToni|);inu-(l  In'  loostiu-d  teerh, 
demand  renio\al  ot  the  teeth,  tojic-rlu-i  with  the  aKrolar  process  ot  the 
jaw.  I  his  nia\  i-asil\'  he  acconiplislu-d  with  eiitrin^  torceps.  Ileinor- 
ihat;^-  ina\  hi-  contiolkil  with  pressure  or  hy  the  eaiirei\.  I  he  latter 
acts  also  as  a  safeguard  against  recurrence.  In  neglected  cases,  where 
the  growth  has  in\()l\ed  a  considerahle  portion  of  the  jaw,  a  resection 
ot  the  jaw  has  been  doiu.  i'.\fn  in  the  \er\'  extensive  cases,  unless 
the  growth  has  been  rapid,  conserxatne  operation  should  he  gi\en  first 
trial.  In  rieanng  epulides  of  the  upper  jaw  care  must  he  taken  to 
determine  whether  or  not  growth  has  extended  into  the  antrum.  Ihis 
is  likely  to  occur  w  Iumi  tiu-  rumor  is  situated  near  the  canine  teeth. 

Alveolar  Granuloma.  Among  the  most  common  tumors  of  the 
gums  are  exuberant  granulations  springing  from  an  area  irritated  b\' 
a  carious  tooth,  or  a  local  infection.  Ihey  \ary  in  size  from  a  pea  to 
a  cherry.  They  are  reddish  or  bluish  in  color,  vascular,  and  soft  to  the 
touch.  I  hey  bleed  readily  when  injured.  Ihex'  spring  up  quickly 
and  remain  stationarw  Their  surface  is  onl\'  in  part  covered  by  epi- 
thelium, the  summit,  at  least,  being  formed  by  granulation  tissue.  1  hey 
are  formed  ot  vessels  and  granulation-tissue  cells  in  close  association, 
lo  the  novice  the  picture  resembles  malignancy,  and  the  diagnosis 
"angiosarcoma"  is  frequently  returned.  This  error  is  particularly 
likely  to  occur  when  a  history  of  recurrence  is  given. 

Diagnosis. — Their  close  association  w-ith  the  teeth,  particularly- 
diseased  ones,  their  vascularit}',  and  disposition  to  bleed  characterize 
them.  Epuhdes  are  firmer,  often  whiter  or  more  brownish  red,  and 
develop  more  slowly.  The  clinical  history  is  of  greater  importance 
than  the  microscopic  examination.  From  sarcoma  the\'  are  easil\' 
distinguished  b}'  their  softness  and  their  livid  color,  and  b\'  the  fact 
that  having  attained  a  certain  size  the\"  become  stationary.  Sarcoma 
of  like  structure  is  diffuse  and  the  growth  is  continuous. 

Treatment. — Because  of  their  disposition  to  recur,  like  exuberant 
granulation  tissue  elsewhere,  the  base  should  be  destroyed  and  diseases 
ot  the  teeth  corrected.  The  curette,  followed  by  the  electrocautery,  is 
most  convenient,  though  chemical  cauteries  may  be  employed.  Radical 
operation   is  unnecessar}'. 

Carcinoma. — The  gums  are  nor  infrequently  the  starting  point  tor 
carcmoma,  which  usually  begins  as  an  ulcerative  process  about  a  decayed 
tooth,  a  bridge,  or  a  plate,  or  rarely  as  a  papilloma.  Such  an  ulceration 
about  a  decayed  tooth,  which  is  the  usual  case,  differs  from  an  ordinary' 
ulceration   in   having   an   infiltrated   border.       Usualh'   the   bone   about 


336     TUMORS  OF  THE  JAWS,  GUMS,  TEETH,  PERIOSTEUM,  AND  BONE 

the  root  of  the  teeth  is  exposed  and  cancer  plugs  can  be  seen.  The 
ulcer  spreads  along  the  alveolar  process  anteroposteriorly  (Fig.  235), 
and  may  extend  over  the  jaw  and  involve  the  cheek,  the  anterior  pillar 
of  the  fauces,  or  the  floor  of  the  mouth.  If  the  growth  affects  the  upper 
jaw  it  may  involve  the  hard  palate  for  a  considerable  distance  and 
form  a  flat  ulcer  with  granular  floor  and  raised  indurated  border.  Sooner 
or  later  the  lymphatic  glands,  usually  the  submaxillary,  become  in- 
volved. If  the  floor  of  the  mouth  becomes  secondarily  invaded,  the 
same  disposition  to  visceral  metastasis  is  manifest  as  when  carcinoma 
is   primary  m  that  region. 

Fig.  235 


Carcinoma  of  the  alveolar  process:    a,  lip;  h,  toothless  gum  unaffected  by  the  carcinoma. 

Diagnosis. — When  the  bone  is  exposed  the  lesion  is  sometimes  diag- 
nosticated as  necrosis  of  the  jaw,  but  the  edge  of  the  ulcer  is  not  soft, 
as  in  inflammatory  affections,  and  the  bone  is  not  affected  except  where 
exposed.  The  broad  carcinomas  which  spread  over  the  hard  palate 
may  suggest  tuberculosis,  but  the  hard  border  and  irregular  outline 
will  lead  to  the  proper  diagnosis.  Syphilis,  too,  may  be  brought  in 
question,  particularly  when  the  ulcer  involves  the  soft  palate.  The 
syphilitic  ulcer  has  a  soft  border,  is  more  regular  in  outline,  and  fre- 
quently gives  evidence  of  healing  at  some  point.  Besides,  there  is 
frequently  evidence  of  previous  ulcers  in  this  region  or  of  active  syphilis 
elsewhere. 

Treatment. — Nowhere  else  in  the  body  are  carcinomas  more  frequently 
technically  operable  with  greater  certainty  of  speedy  recurrence.  If 
the  floor  of  the  mouth  or  the  cheek  is  invaded,  recurrence  is  certain. 
If  the  lower  jaw  is  invaded,  a  resection  of  the  bone  with  a  complete 
removal  of  the  adjacent  lymphatics  is  demanded  in  every  case.  If  the 
upper  jaw  is  invaded,  the  alveolar  process,  the  horizontal  ramus,  in 
fact,  the  entire  superior  maxilla  except  the  orbital  plate,  together  with 
the  glands,  should  be  removed  in  every  instance.  When  the  tumors 
are  small  it  is  not  easy  to  resist  the  urgent  request  of  the  patient  for 


77  .\i(Jks  /)/:i  /■:i.ori\(:  i  i«)\i  iiii.  nj/ni  :;:;7 

coiisii  \;it  ism,  ;iiul  loo  otitii  tin  sui^ioii  foiittiils  lumsilt  \sitli  tlu- 
iinu)\;il  ot  I  111-  iiKrolai  i^roicss  ()iil\  ;  such  ()|-)ti;it  ions  ;irc-  iii\:ii  i;il)ly 
tollowid    In     nciii  11  luc. 

Rare  Tumors  of  the  Gums.  A  ^ri;ir  v;iiic'r\'  of  rumors  beloiiKiny; 
to  tlu  (.•()niU(.ti\  i-rissuc-  oi-  \;iscul:ii"  j^roup  wifcii  tin-  ji;ums.  Hem- 
;in!i,u)nKis      .iiui      hhioiis      li|>om;is      ;iii- 

sometMiU'S     touiul.        I  In     hhroiiKis    arc-  I-k;.  2^6 

frequenth  pol\  poul,  ol  thf  sr/i- ot  a  jit-a 
or  a  hean,oic\tn  laiji;!.!'  (I'lii.  23M,  and 
causi-  anno\  aiUH'  h\  coniint;  m  (.-ontacr 
with  the  tonuur  or  with  food,  or,  when 
hui^e  enou«2;h,  by  hem*!;  cau^lit  l')etween 
the  teeth.  Not  mfreciuenrl)-,  small 
tumors  formed  of  dentine,  attached 
to  the  soft  part  of  the  jaw  only,  are 
observed.  I'hey  are  probabl)'  due  to 
the  sirowtli  of  a  cell  nest  displaced 
during  the  development  of  the  teeth. 
None  of  these  tumors  offers  any  diffi- 
cult\-  in  diagnosis,  and  if  b}'  their  size 
the\'  cause  annoyance,  simple  removal 
results  in  a  permanent  cure.  Hard  papillnma  of  rhu  jntlarc. 


TUMORS    DEVELOPING   FROM    THE    TEETH 

Ihe  abnormal  development  of  the  teeth  or  dental  sacs  gives  rise 
to  a  variety  of  conditions  within  the  body  of  the  jaw.  When  these 
anomahes  approach  mature  development,  they  produce  bony  tumors. 
When  the  cellular  tumors  are  produced  in  the  latter  by  secondary 
processes,  c\sts  develop. 

Odontomas. — This  term  was  introduced  b}'  Broca  for  tumors  result- 
ing from  oN'erproduction  of  some  of  the  bon\'  elements  of  the  teeth. 
They  are  hard  nodular  tumors  which  raise  up  the  wall  of  the  jaw  (Fig. 
237).  The\'  disappear  before  the  teeth  are  fully  developed;  but  since 
the\"  frequently  grow  from  wisdom  teeth,  the\"  ma\'  occur  after  the 
period  of  adolescence. 

Diagnosis.  -The  development  of  odontomas  is  slow  and  symptom- 
less but  for  the  deformity  produced.  Their  nature  ma\"  be  suspected 
from  the  slow-  growth  and  the  irregularity  of  outline  and  from  the  absence 
or  rudimentary'  state  of  the  teeth  at  the  region  affected.  The  proof 
must  depend  upon  the  recognition  of  the  bone-like  tumor  after  its 
exposure  during  the  operation. 


338      TUMORS  OF  THE  JAWS,   GUMS,    TEETH,  PERIOSTEUM,  AND  BONE 

Treatment. — The  growth  should  be  exposed  by  the  removal  of  the 
bon}^  tissue  of  the  jaw  covering  it  and  removed.  This  is  frequentl}^ 
made  easy  b}^  the  presence  of  a  complete  capsule.  The  lining  of  the 
cj^st  should  be  taken  out  with  a  sharp  spoon  or  rongeur.  When  inti- 
mately associated  with  the  alveolar  border,  odontomas  ma}^  frequently 
be  removed  through  the  mouth  by  means  of  the  cutting  forceps. 

Fig.  237 


Odontoma  of  lower  jaw.     (Von  Bergmann.) 

Adamantomas. — These  tumors  grow  from  embryonal  cells  associated 
with  the  development  of  the  teeth.  They  are  cellular  growths,  often 
gland-Hke  in  structure,  and  often  intermingled  with  cystic  areas. 

Diagnosis. — They  develop  during  the  adolescent  period,  producing 
expansion  of  the  jaw,  and  when  they  occur  in  the  upper  jaw  may  fill 
the  antrum.  Their  slow  and  painless  growth  suggests  their  nature, 
which  can  be  proved  only  when  the  tumor  is  exposed  during  operation. 
The  complete  encapsulation  and  freedom  from  attachment  to  the  bone 
distinguish   them  from  sarcoma. 

Treatment. — The  local  removal  results  in  a  cure.  The  capsule,  if  one 
exists,  must  be  removed,  and  if  none  exists,  a  portion  of  adjacent  bone 
should  be  removed  by  means  of  a  curette  or  cutting  forceps.  Only 
rarely  in  neglected  cases  is  it  necessar}^  to  resect  the  bone  in  continuit}^ 

Odontoid  Cysts. — Under  this  head  have  been  described  cysts  of 
the  jaw  which  appear  to  originate  in  some  developmental  anomal}^ 
of  a  tooth,  usually  a  permanent  one.  The  cyst  walls  are  formed  of 
epithelial-like  cell  masses  which  in  their  growth  expand  the  jaw  and 
produce  a  globular,  spindle-formed,  or  lobulated  tumor  similar  to  the 
soHd  tumors.  They  frequently  contain  a  poorly  developed  tooth, 
and  seem  to  be  a  connecting  link  between  the  adamantomas  and  the 
cysts.     Like  the  solid  tumors,  the}^  may  be  confined  to  the  horizontal 


77  MfjRs  or  Tin:  I'I.riostu  m  .i\i>  Hfj\j:s  ;;;{•) 

ramus  or  ni:i\  iinolvi-  rlu-  iiulii-  jaw.  I  In  iliiiuuss  ot  tlu  hoiu-  \aric-s 
in  diHiiciii  lasis.  !•  ir(|ucntl\  ii  is  so  ilim  that  a  (.larklin^  soiind 
IS  inoclintd  h\  [mssim-.  ( )c-(.-asionall\  tlu-  lioin  wall  is  l)i(»kfn  cnrircly 
rliiou^h  ami  tlu  (.•oiutius  cscapt-  into  tin-  sin  louiuiiiiji  tissue.  Infec- 
tion of  ilu  ».\stu-  (.-ontints  ma\'  take  place.  I  In-  eavit\'  of  the  cyst, 
which  contains  stia w-coloi cd  Huid,  is  l'i((iu(iitl\  di\ided  1)\  hon\'  septa. 
I'.arh  in  tlu  couisi  ot"  dt\  c  lopnieiit  neuial^ia-like  jiams  nia\  he  felt 
in  the  teeth,  hut  asuli-  iVoni  this  the  only  manifestation  is  the  ^raduall)' 
eI1la^^in^  tumor.  When  it  Incomes  ven"  larj^e  it  ma\  press  upon  the 
toniiue,   or   nia\     inriit'ere   with    the   nio\enu-nrs   ol    the   inferior   maxilla. 

Diagnosis.  Tin  cystic  tumors  of"  the  jaw  cannot  he  differentiated 
from  the  solid  with  certainty  before  operation.  C\sts  ma\'  be  sus- 
pected when  the  walls  are  so  thinned  that  a  paichnunr-hke  crackling 
is  manifest  on  pressure.  From  odontomas,  they  can  he  distinguished 
onl\-  at  operation.  From  m\eloid  sarcomas,  they  can  be  distinguished 
b}-  their  slow  growth.  M'he  absence  of  a  tooth  or  the  presence  of  a 
primary  tooth  after  a  permanent  tooth  should  ha\e  displaced  it  points 
to  this  class  of  affection. 

Treatment. — The  older  authors  ( Heath  j  advise  opening  the  cysts  into 
the  mouth.  Present  practice  seems  to  lean  toward  a  more  radical 
treatment.  The  exsection  of  the  walls  w  hen  possible  should  be  practised. 
At  most,  a  bridge  of  bone  can  be  left  in  order  to  retain  the  outline  of 
the  alveolar  process.  If  cysts  are  merely  curetted,  there  ma\-  be  a 
recurrence,  which  then  will  require  a  radical  operation. 

Periosteal  Cysts. — Resembling  somewhat  the  foregoing  are  the  so- 
called  periosteal  cysts  which  occur  about  the  roots  of  carious  teeth 
in  adults.  TheA"  do  not  attain  the  size  of  odontoid  CAsts,  but  may 
involve  the  antrum.  Removal  of  the  diseased  teeth  and  curettage  of 
the  cavit\'  results  in  a  cure. 


TUMORS    OF   THE    PERIOSTEUM    AND    BONES 

Sarcoma. — The  jaw  is  one  of  the  most  frequent  sites  of  sarcoma, 
the  upper  and  lower  being  affected  in  about  the  same  proportion.  Nine- 
tenths  of  the  tumors  of  the  jaws  are  sarcomas.  In  the  lower  jaw 
endosteal  tumors  are  encountered  as  well  as  periosteal,  while  in  the 
upper  jaw  the  former  are  infrequent  because  of  the  thinness  of  the 
plates. 

The  endosteal  or  myelogenous  sarcomas  of  the  lower  jaw  are  usually 
giant-celled  tumors  exhibiting  the  reddish  structure  common  to  this 
variety.  Their  clinical  character  is  dependent  on  their  predominant 
cell  t\pe.      By   their  gradual  growth   the\-  cause  a   nodular  or  fusiform 


340      TUMORS  OF  THE  JAWS,  GUMS,   TEETH,  PERIOSTEUM,  AND  BONE 

enlargement  of  the  bone.  The  bony  covering  becomes  gradual!}'  thinned, 
so  that  crackling  is  produced  upon  palpation.  The  teeth  become 
loosened,  and  either  fall  out  or  are  easily  removed.  With  continued 
growth,  the  bouA'  plates  are  perforated  and  the  tumor  extends  into  the 
surrounding  soft  parts.  Fungous  masses  may  protrude  from  the  open- 
ings left  bv  the  extracted  teeth,  and  be  subject  to  injury  during  mastica- 
tion and  to  infection  by  the  buccal  flora.  The  cheek  may  become 
invaded  and  ulcerating  crateriform  masses  produced,  which  may  give 
rise  to  troublesome  or  even  fatal  hemorrhage. 


Fig.  238 


Fig.  239 


Periosteal  sarcoma  of  the  lower  jaw, 


Sarcoma  developing  from  the  alveolar 
periosteum. 


The  periosteal  sarcoma  (Fig.  238)  may  be  composed  of  an}-  cell  tA'pe 
or  a  mixture  of  types,  and  frequenth'  there  is  a  large  proportion  of  fibers. 
This  fact  has  caused  man}^  of  them  to  be  reported  as  fibromas  ol  the 
jaw,  particularly  by  the  older  writers,  and  for  this  reason  the  older 
reports  are  quite  useless  for  statistical  purposes.  Notwithstanding  the 
prominence  of  fibrous  tissue,  they  are  very  malignant  tumors.  They 
form  at  first  a  nodular  or  a  spindle-form  enlargement  upon  any  part 
of  the  surface  of  the  jaw,  and  ma}"  at  this  stage  resemble  a  periosteal 


TlMUkS  (J I    Till.    ri:kl()SThl  M     IM)   li()\ES 


341 


iiiriaiiiniation;  their  extension  to  tlu  lutks  of  the  teeth  and  the  attend- 
ing suppuration  add  to  this  lesenihlaiui-.  I  hey  usuall\  tend  (juickly 
to  in\ade  the  siiiroiindin^  tissue  and  to  piifoiate  the  cheek,  with  the 
saini'  attiiulant  phmoiiuiia  as  are  nofiied  m  the  nnelo^tnous  t\  pe. 
Neifhn  class  tends  to  early  lymphatic  iinasion,  hut  \isceral  metastasis 
m  the  periostea!  t\  pes  is  fre(pientl\  an  eaiiv  complication.  I  suall\ 
hemoii  hajie,  pain,  inteifeieiice  with  nutiition,  either  hy  the  mjiestion 
ot  putriHed  products  ot  tlu  tumor,  or  h\  mechanical  hindrance  to 
mastication  or  deglutition,  reduce  the  patient  to  a  point  where  pneu- 
monia  or   some   other   intercurrent   disease   finds   him    an    eas\'   victim. 


Vv 


Sarcoma  of  the  antrum. 


Sarcoma  of  the  superior  maxilla  may  be  periosteal  (Fig.  239)  or  may 
develop  within  the  antrum  (  Fig.  2401,  the  latter  being  the  more  common. 
Often  when  the  disease  is  advanced  the  point  of  origm  cannot  be  made 
out  with  certainty.  The  invasion  of  the  surrounding  tissue  is  often 
extensive;  the  orbit  and  nasal  fossa   particularly  are  often  attacked. 

Diagnosis. — Myelogenous  sarcoma  of  the  jaw  is  simulated  by  many 
conditions  which  cause  expansion  of  the  bony  plates,  most  frequently' 
hy  odontomas  and  dentigerous  cysts.  These  benign  tumors  are  indi- 
cated by  slower  growth  and  displacement  of  teeth.     Epulis  may  cause 


342      TUMORS  OF  THE  JAWS,  GUMS,   TEETH,  PERIOSTEUM,  AND  BONE 

loosening  of  the  teeth  and  may  extend  into  the  mouth,  but  when  there 
is  expansion  of  the  jaw  or  severe  pain  the  graver  disease  is  probably 
present.  There  is,  however,  no  sharp  distinction  between  epulis  and 
sarcoma;  the  character  of  the  tumor  is  the  same,  the  difference  being 
merely  one  of  location.  By  extension  through  the  bone,  the  malignant 
character  of  the  growth  is  definitely  declared. 

Necrosis  of  the  jaw,  tuberculosis,  and  actinomycosis  may  resemble 
sarcoma  very  closely,  and  the  clinical  characters  of  the  affection  must 
always  be  considered.  The  periosteal  type,  because  of  its  exposed  posi- 
tion and  more  rapid  growth,  usually  permits  of  an  easy  diagnosis.  In- 
flammatory affections  usually  may  be  differentiated  by  their  history. 
The  more  slowly  growing  sarcomas  may  be  confused  with  osteomas, 
especially  since  this  type  of  sarcoma  is  frequenth^  attended  by  the 
formation  of  bone.  The  osteomas,  however,  are  less  frequently  spindle- 
form  and  are  of  a  slower  growth.  After  all  means  of  diagnosis  have 
been  exhausted,  the  surgeon  is  sometimes  compelled  to  proceed  to 
operation  on  a  probable  diagnosis,  expecting  to  vary  his  operative  pro- 
cedure according  to  the  findings  after  exposure  of  the  tumor.  This  is 
particularl}^  true  of  tumors  suspected  to  be  myelogenous  sarcomas.  When 
exposed  to  view,  the  reddish  solid  or  cystic  sarcomas  can  easily  be  differ- 
entiated from  the  inflammatory  conditions  and  the  dentigerous  anomalies. 

Sarcomas  of  the  superior  maxilla  less  frequently  offer  difficulties 
in  diagnosis,  because  usually  when  patients  present  themselves  for 
examination  the  tumor  has  advanced  to  such  a  stage  that  the  diagnosis 
is  clear  (Fig.  241).  Tumors  which  go  out  from  the  alveolar  process 
with  the  characteristics  of  periosteal  sarcoma  usuall}^  show  their  char- 
acter by  their  rapid  growth  and  by  their  primary  origin  from  sites  other 
than  the  dental  periosteum.  Those  which  grow  within  the  antrum 
ma}'  bulge  and  cause  a  prominence  on  the  cheek,  in  the  orbit,  on  the 
nasal  wall,  or  in  the  nasal  cavity,  in  the  last  case  resembling  nasal 
polyps.  When  the  tumors  have  extended  beyond  these  limits  they 
present  diagnostically  neither  interest  nor  difficulty.  The  soft  parts 
may  be  infiltrated  and  ulceration  or  hemorrhage  follow.  More  fre- 
quently the  orbit  ma}^  be  invaded,  causing  dislocation  of  the  eye  and 
perhaps  ulceration  and  blindness.  The  cranial  cavity  may  be  invaded 
and  symptoms  of  cerebral  compression  may  arise. 

Treatment. — Opinions  as  to  the  treatment  of  sarcoma  of  the  jaw  have 
not  yet  been  adjusted  to  the  changes  in  view  which  have  modified 
the  treatment  of  sarcoma  of  the  long  bones,  and  radical  operation  is 
usually  advised  in  all  cases.  The  medullar}^  sarcomas  may  be  sub- 
jected to  conservative  treatment  provided  the  surrounding  tissue  has 
not  been  invaded.  When  this  has  occurred,  however,  radical  removal 
is  necessary.     The  periosteal  type,  including  sarcomas  of  the  antrum, 


77  MORS   or   I  III:    I'E KKJSTIA  M     IM)   liOMlS 


343 


cUiiKiiul  ilu-  ic-m()\al  of  rlic  hone.  Siiuc  tlu  l\  in|ih;itu  s  .m-  i.ncly 
imaiiiil,  ilu-  iitrc-nrion  ot  ilu-  sinLitoii  should  he  ;;i\in  lo  adcciuate 
local  iiiiioxal.  So  (liNiisi-  aif  tlu-  loiiiscs  wliuli  iiuiiNuluaJ  cast-s  iiin 
that  {iciuial  iiiKs  raiiiiol  \n-  laid  ilowii.  I  siialK  iii  ihc  ia|Mdl\  ^lo\Miif; 
ptriostial    ( \  [hs   all    tnainunt    lads. 


Sarcoma  of  the  superior  maxilla. 

Chondromas. — Chondromas  are  found  m  both  upper  and  lower 
jaws,  but  much  more  frequently  m  the  latter.  \  hey  may  develop  as 
solitarA'  growths,  together  with  similar  processes  elsewhere.  They 
maA'  arise  from  the  surface  of  bones,  including  the  wall  of  the  antrum, 
or  from  the  medullar}'  cavity.  The)'  develop  slowly  and  expand  the 
bone  when  the\'  grow  from  the  medulla  or  in  the  antrum.  They  ma}' 
form  a  diffuse  enlargement,  but  the  base  is  usually  more  or  less  con- 
stricted. 1  he  disturbance  they  cause  m  the  body  is  purel\'  mechanical. 
Like  chondromas  elsewhere,  their  nature  is  always  open  to  suspicion, 
and  the  more  so  the  more  rapidly  they  grow.  Frequently,  when  no 
evidence  of  malignanc\'  can  be  found  with  the  microscope,  they  recur 
after  removal,  and  in  the  course  of  time  the  recurrences  show  definite 
sarconiatous  elements. 

Diagnosis.  Their  topography  being  considered,  their  character  can 
be  suspected  from  their  density  and  rate  of  growth,  but  can  actualh' 
be  demonstrated  onh'  on   section. 


344     TUMORS  OF  THE  JAWS,  GUMS,   TEETH,  PERIOSTEUM,  AND  BONE 

Treatment. — Operative  removal  should  be  undertaken  as  soon  as  they 
are  discovered,  because  by  incision  only  can  their  nature  be  definitely 
determined;  their  early  removal,  because  of  their  doubtful  character, 
is  always  desirable. 

Osteoma. — Bone  tumors  occur  in  the  same  situations  and  present 
the  same  evidences  as  chondromas.  They  are  of  slower  growth  and 
of  an  innocent  character,  and  cause  mischief  solely  by  pressure. 

Diagnosis. — Their  density,  slowness  of  growth,  and  location  char- 
acterize them.  Inasmuch  as  bone  tissue  is  frequently  present  in  malig- 
nant growths,  the  possibility  of  malignancy  should  always  be  assumed 
when  the  tumors  develop  rapidly,  and  in  such  cases  early  removal 
is  demanded. 

Treatment. — Local  removal  is  sufficient,  though  when  they  are  in 
the  antrum  or  in  the  centre  of  the  inferior  maxilla  it  is  necessary  to 
remove  normal  bone  in  order  to  gain  access  to  them. 

Fig.  242 


Lobulated  fibroma  of  the  gums  from  irritation  of  a  dental  plate.      (Von  Bergmann.) 

Fibroma. — As  stated  in  the  discussion  of  sarcoma,  the  malignant 
tumors  frequently  have  a  distinctly  fibrous  appearance,  but  true  fibromas 
which  form  masses  extending  about  the  inner  border  of  the  gums  are 
sometimes  observed.  They  may  follow  ill-fitting  plates  but  may  develop 
in  gums  when  the  teeth  are  still  present  and  still  normal.  Walls  of 
fibrous  tissue  sometimes  have  the  appearance  of  a  second  toothless 
alveolar  process  (Fig.  242).  Fibromas,  both  endosteal  and  periosteal, 
have  been  described,  but  they  are  infrequent.  Careful  examination 
of  every  part  of  the  tumor,  together  with  an  account  of  the  subsequent 
history  of  the  patient,  should  be  demanded  before  the  diagnosis  of 
fibroma  is  accepted.  Such  critical  analysis  would  probably  greatly 
reduce  the  frequency  of  these  already  rare  tumors. 


C  II  A  I'  T  I',  R     X  X  \    I    I 

TiMORs  oi'  'iiii-;  PAkorii)  ANi:)  srmiAxii.i.Ain'  ci.anos 

I  HI-,  tuinois  ot  tin-  p;ii()ri(l  and  suhmaxillai  \  ;;laiuls  lia\t-  itukIi  in 
coiiinion,  rlu'  only  difference,  aside  from  topo^iraphical  relations,  heinji 
that  they  occur  much  more  frecjuently  in  the  parotid  f^land;  the  same 
description,  therefore,  will  appl\'  to  both.  The  many  classes  of  tumors 
in  these  glands,  described  by  the  older  writers,  have  in  the  light  of  newer 
studies  come  to  be  regarded  largely  as  merely  varieties  of  the  mixed 
tumors. 

Mixed  Tumors.  The  vast  majority  of  the  parotid  and  submaxillar\- 
tumors  are  composed  of  a  variety  of  tissues,  and  have  very  appropriarel\- 
been  called  mixed  tumors.  These  tumors  occur  usuall\'  between  the 
twentieth  and  thirtieth  \-ears,  equally'  in  the  two  sexes  and  without 
known  cause. 

Macroscopic  Structure. — At  first  these  tumors  lie  isolated  beneath  the 
capsule  of  the  parotid  gland.  They  are  more  or  less  perfectly  encapsu- 
lated and  are  usually  globular,  sometimes  with  slight  bosselations. 
As  the\-  become  larger  the}'  displace  the  tissue  and  the  bosselations 
become    more    prominent. 

On  section,  the  mixed  character  of  the  tumors  is  usualh'  at  once 
apparent.  Bluish  areas  dense  to  the  touch  bespeak  the  presence  of 
cartilage,  pinkish  semisolid  areas  indicate  m\'xoid  tissue,  while  whitish 
punctiform  or  striated  areas  mark  the  more  cellular  areas  (Fig.  243), 
and  intermingled  with  all  are  bands  of  connective  tissue.  The  propor- 
tion of  these  tissues  is  variable.  The  cartilage  ma}'  be  entirelv  absent 
and  the  myxoid  tissue  may  not  be  discernible  by  gross  inspection,  so 
that  the  general  appearance  is  of  fibrous  tissue  with  small  punctiform 
areas  of  white;  or  these  white  cellular  areas  may  be  much  larger  and 
more  prominent.  These  last  two  types  are  more  common  in  the  sub- 
maxillary tumors.  As  more  rapid  growth  takes  place  the  general  char- 
acters change.  The  surface  of  the  tumor  becomes  distincth'  nodular 
(Fig.  244),  and  in  very  advanced  cases  the  capsule  may  be  perforated 
and  the  surrounding  tissue  invaded.  I'he  rapid  growth  finds  expres- 
sion also  in  a  change  in  structure,  which  on  section  becomes  apparent 
in  the  proportionate  increase  of  the  white  cellular  areas,  and  often  b\' 
displacement  of  the  myxoid  and  cartilaginous  tissue  by  a  central  area 


346        TUMORS  OF  THE  PAROTID  AND  SUBMAXILLARY  GLANDS 


of  necrosis  (Fig.  245),  which  may  be  of  considerable  extent.  It  is  3^1- 
lowish  gray  in  color,  and  is  usually  dry  and  cheesy,  but  may  liquefy 
and   form  a  cyst. 

Fig.  243 


Mixed  tumor  of  the  parotid. 
Fig.  244 


Mixed  tumor  of  the  parotid,  showing  nodules  in  active  proliferation,  but  the  capsule 

is  intact. 


MicRoscoi'ic  .//'/'/■:. n<./.\(:/:  oi    mim.d  tlmors 


347 


Microscopic  Appearance.       I  lu-  i;ii  tilauiiioiis   ;iiul    myxoid   elements  are 
usiKilU   oln  ions  ;ii  ;i  iihiiui  iiiulci  the  nmroscope  e\iii  wlu-n  not  :ip)"):irent 


Ik;.  245 


Mixed  tumor  of  rhc  parorul,  wirh  in\H)l\  cmcin  ot    tin-   l\  mph  glands. 

on  gross  section.  The  main  interest,  however,  centres  about  the  cellular 
elements,  on  account  of  the  difference  of  opinion  which  still  exists  rela- 
tive to  their  source  and  significance.     Some  hold  that  the  various  tissues 


348        TUMORS  OF  THE  PAROTID  AND  SUBMAXILLARY  GLANDS 

are  all  of  similar  origin  and  result  from  metamorphosis.  The  cells 
have  been  regarded  b}^  some  as  epithelial,^  but  the  consensus  of  opinion 
is  in  accord  with  Wilms,  that  the  tissues  are  of  independent  origin 
and  that  the  cells  are  endothelial.  Many  German  authors,  following 
Volkmann,-  regard  the  mixed  tumors  as  essentially  endotheliomas,  and 
classif}'  them  with  this  group;  but  the  presence  of  the  cartilaginous 
and  mj^xoid  tissues  are  more  than  accidental,  since  the}'  often  make 
up  the  bulk  of  the  tumor,  particularly  in  early  stages.  The  cellular 
elements   are   sometimes  gland-like   in   their   arrangement,  with   similar 

Fig.  246 


Mixed  tumor  of  the  parotid,  showing  endothelial  areas  undergoing  active 

proliferation. 

cells  interspersed  in  the  interstitial  tissue  (Fig.  246);  in  other  regions 
the  cells  have  the  arrangement  of  endotheliomas  (Fig.  247),  and  usually 
areas  typical  of  this  class  can  be  found  somewhere  in  the  tumor.  When 
rapid  development  begins  these  cells  become  active,  often  lose  the 
distinct  character  of  endothelioma,  and  are  diffused  throughout  the 
connective    tissue.      The   cells    then    may   be   larger   and    contain    more 

1  Hinsberg,  Deutsch.  Ztschr.  f.  Chir.,  1899,  li,  281. 

2  Deutsch.  Ztschr.  f.  Chir.,  1895,  xli,  I. 


ci.iMc.ii.  (:(f{  rsj:  or  mixed  n  mors  ;j4<) 

protoplasm.       I  Ik-    ciulotlulioinaroiis    ananiicnu-nr    is    usuall\     iiuiit'ly 
lost   ill   tlu-   iiutastasc's. 

Kic.  247 


C"''' -."!5'«  AV   •••  e.>''  ♦•■?••'.•.•-'..  V.  •  ;.  ;    .  ;v     •>  • ..:  iA 

Endotheliomatous  area  of  mixed  tumor  of  parotid.     Lymph  gland   metastasis  showed 

similar  structure  and  distinctly  sarcomatous  areas. 

Clinical  Course. — The  development  is  usually-  ver\"  slow,  these  tumors 
having  often  existed  for  ten  to  fort\-  \ears  before  the  patient  seeks 
advice.  The  growth  is  often  scarcely  perceptible  from  year  to  year,  and 
during  this  stage  the  tumors  are  but  partl\-  Hxed  and  the  skin  is  freely 
movable  over  them.  The\-  appear  to  be  subcutaneous  (Fig.  248),  but 
their  location  within  the  parotid  imparts  a  definite  limitation  of  motion. 
In  nearly  all  cases  rapid  growth  begins  sooner  or  later,  and  is  often 
accompanied  b}"  dull  pain  and  annoying  salivation.  With  more  exten- 
sive growth,  particularly  when  the  surrounding  glands  are  involved, 
the  entire  region  of  the  parotid  becomes  diffusely  enlarged  (Fig.  249), 
and  no  definite  outline  to  the  tumor  is  perceptible.  The  lobe  of  the 
ear  is  carried  upon  the  summit  of  the  tumors,  and  involvement  of  the 


350       TUMORS  OF   THE   PAROTID  AND  SUBMAXILLARY  GLANDS 

facial  nerve  may  become  manifest  by  facial  paralysis.  Sometimes 
the  tumor  itself  may  show  but  little  evidence  of  activity,  while  the 
lymph  glands  of  the  neck  are  extensively  invaded.  Distant  metastases, 
particularly  in  bones,  sometimes  take  place  early. 

The  submaxillary  tumors  follow  the  same  general  course  as  the 
parotid  tumors  and  present  the  same  physical  findings.  They  project 
immediately  in  front  and  below  the  angle  of  the  jaw  and  just  behind 
the  facial  artery  (Fig.  250). 


Fig.  248 


% 

m 

J 

f^^4: 

^^^^^^^S|^^^B 

w 

1 

n 

Mixed  tumor  of  the  parotid  gland. 

Diagnosis. — The  location  of  a  tumor  within  the  capsule  of  the  parotid 
or  submaxillary  gland  is  usually  alone  sufficient  for  diagnosis,  and  a 
history  of  long  duration  with  sudden  exacerbation  and  the  appearance 
of  nodulations  on  the  tumor  is  strongly  confirmatory.  Adenomas 
forming  smooth  circumscribed  tumors  are  sometimes  seen,  but  many 
of  these  will  be  found  on  close  examination  to  be  mixed  in  character. 
The  same  may  be  said  of  the  chondromas.  The  lymph  glands  situated 
over  the  parotid  are  sometimes  the  seat  of  secondar}/  tumors,  par- 
ticularly melanomas;  the  identification  of  these  depends  largely  on 
the  result  of  a  search  for  the  primar}^  growth.  The  carcinomas  are 
rare  and  are  distinguished  by  their  irregular  outline  and  great  density. 

Treatment. — When  presented  for  treatment  before  active  prolifera- 
tion  has   begun,    local   excision   can   easily   be   done   with    preservation 


CI.IMC.II.    C.Ol  RSI:    or    Ml\l.l>    It  MORS 


iiol 


oi  Sttnson's  tliK't  and  thr  facial  iui\t,  rlu-  incision  l>cinji  prc-tt-rahly 
above  the  ncixi-  and  paiallil  wirli  it.  Ilu-  tumor  can  he  rcniovcd  hv 
Miint  liisscction.  Attn  acii\t-  ^lowili  lias  bt^iiii  tin-  prol)liin  is  less 
siinpK-.  ()tun  the  hulk  dT  tin-  tumor  lu  s  in  the  nt  lomaxillaiy  tossa, 
and  it  ma\  he  diHiculr  to  dislodge  it.  An  txammarion  h\  palpation 
thfouuh  till-  mouth  .shouKl  al\\a\  .s  In-  made  hetoie  the  opeiation  i.s  he;;uii. 


Fl(..    24< 


Mixed  tumor  of  tlif  parotid  y,laiul.     K.\ten.si\t  in\  ol\  eiiicnt  ot  tlie  cervical  lymph  glands. 

The  entile  gland  must  he  sacrificed  when  the  growth  has  become 
extensive,  when  the  capsule  is  invaded,  and  when  the  l\-niph  glands 
are  involved.  In  such  cases  it  ma\'  still  be  possible  to  save  the  facial 
nerve;  it  should  at  least  Hrst  be  located  and  an  attempt  made  to  set 
it  free,  although  often  the  tumor  will  have  surrounded  it  in  such  a  manner 
that  its  liberation  is  either  impossible  or  beyond  the  technique  of  the 
surgeon.  A  sharp  knife  applied  under  full  vision  will  succeed  more 
often  than  the  dull  dissection  usually  recommended.     When  the  nerve 


352        TUMORS  OF  THE  PAROTID  AND  SUBMAXILLARY  GLANDS 

has  been  liberated,  or  inadvertentl}'  destroyed,  the  tumor  must  be 
removed.  When  the  neck  is  extensively  involved,  a  block  dissection 
is  required  sometimes  even  to  the  resection  of  the  artery  and  pneumo- 
gastric  nerve.  The  submaxillary  gland  is  usually  sacrificed  in  parotid 
tumors  as  a  matter  of  convenience.  In  extensive  operations,  where 
the  common  carotid  is  not  sacrificed,  it  is  often  convenient  to  ligate 
the  external  carotid  as  soon  as  it  is  exposed  in  the  dissection  before 


Fig.  250 


Mixed  tumor  of  the  submaxillary  gland. 

the  tumor  is  dislodged.  This  step  is  particularly  helpful  where  the 
retromaxillar}'  fossa  is  filled  with  tumor  mass.  In  tumors  of  the  sub- 
maxillary gland  the  problem  is  usualh'  much  more  simple.  The  tumors 
of  this  gland  are  less  prone  than  the  parotid  to  rapid  growth,  and  when 
they  are  presented  for  operation  they  are  still  encapsulated  and  can 
be  readily  shelled  out,  not  from,  but  together  with,  their  capsule.  Ex- 
tensive operations  may  be  required  when  the  capsule  has  been  invaded 
or  the  h^mph  glands  involved. 


R.IRI:    ri  MORS  353 

Radical  operations  upon  inixiil  tmnois  are  worth  while,  for  when 
completely  removed  the  prospiets  ot  a  cure  are  j^ood,  much  hertii  than 
with  carcinoma  or  sarcoma  of  the  same  extent. 

Rare  Tumors.  I  umois  ot  these  glands,  aside-  from  riu-  mixed  rumors, 
may  well  he  classed  as  rare.  Sarcomas'  have  heen  descrihed,  hut  the\' 
prohahl\  represent  the  malignant  stage  of  the  mixed  tumors.  Carci- 
nomas undouhtedl)  do  occur,-  usually  as  dense  slowly  growing  tunK^rs, 
or  more  rapidly  growing  ones  with  ulceration  of  the  overlying  skin. 
.Adenomas'  and  chondromas  may  occur,  hut  careful  examination  must 
he  made  to  exclude  mixed  tumors.  Myomas  have  been  descrihed, 
hur  without  douhr  leinesent  the  mixed  tumors.  Angiomas^  may  occur 
withm  the  gland.  1  hey  must  be  distinguished  from  angiomas  of  the 
skin  covering  the  gland  which  is  a  common  site.  Lipomas^  within 
the  gland  have  been  described.  None  of  these  tumors  occurs  with  suffi- 
cient frequency  to  warrant  a  description  or  to  permit  the  formulation 
of  a  distinct  line  of  treatment. 

'  Ivaufmann.  Arch.  f.  klin.  Chir.,  iSSi,  xxvi,  672. 

-  Micheau,  Cancer  de  la   Parotid,   I  hese  de  Paris,  1884. 

^  Nasse,  Arch.  f.  khn.  Chir.,  1892,  xliv,  233. 

^  Lannelogue  and  .Achard,   I  raite  des  Kystes  congeniteaux,  Paris.  1886. 

'"  Demarquay,  Bull,  et  mem.  de  la  soc.  de  Chir.,  1873,  li,  12. 


23 


CHAPTER    XXVIII 

TUMORS  OF  THE  NECK,  INCLUDING  TUMORS  OF  THE 

THYROID  AND   PARATHYROID  GLANDS,  AND 

CAROTID  TUMORS 

General  Conception. — There  is  no  region  of  the  bod}'  so  fruitful 
in  tumors  as  the  neck,  nor  one  in  which  tumors  demand  so  careful 
differentiation.  True  primary  neoplasms  are  somewhat  rare;  but  con- 
genital anomalies,  branchiogemc  CASts,  secondary  carcinomas,  certam 
obscure  diseases  of  the  Ij^mph  glands,  and  inflammations  which  are 
characteristic  of  the  neck  provide  subjects  for  the  broadest  laboratory 
and  clinical  judgment. 


PRIMARY  TUMORS  OF  THE  LYMPH  GLANDS  OF  THE  NECK 

All  primar\^  tumors  of  the  lA^mph  glands  have  much  in  common, 
and  it  is  often  hard  to  distinguish  them  apart;  but  there  are  certain 
differences,  both  clinical  and  microscopic,  that  make  a  distinction 
possible. 1  The  importance  of  this  matter  lies  in  the  fact  that  the  prog- 
nosis varies  with  the  t^^pe.  These  tumors,  named  in  the  order  of  their 
frequenc}',  are  Hodgkin's  disease,  lymphosarcoma,  and  sarcoma  of  the 
l3^mph  glands.  ^ 

Hodgkin's  Disease  ("Malignant  Lymphoma;  Pseudoleukemia). — By 
this  IS  usuall}'  understood  a  disease  characterized  b}'  progressive  en- 
largement of  the  lymph  glands,  which  begins  usually  in  the  cervical 
group  and  spreads  to  others.  It  is  attended  by  general  bodil}^  deteriora- 
tion, which  leads  to  a  fatal  termination  in  from  two  to  five  years.  Its 
relationship  to  the  true  tumors  has  not  been  definitely  established. 
There  is  a  gradual  transition  from  this  disease  to  the  lA'mphosarcomas, 
and  some  authors  would  class  the  two  diseases  together.  In  the  present 
description  they  will  be  considered  separately.  Its  close  relation  to 
the  tumors  is  emphasized  b}'  the  fact  that  Hodgkin's  disease  is  now 
treated  by  operative  removal.  In  fact,  German  writers-  designate 
It  by  the  term  malignaiit  lymphoma,  which  indicates  at  once  the  seat 

^  W.  G.  MacCallum,  Johns  Hopkins  Hosp.  Bull.,  1907,  xviii,  337. 

^  See  F.  Fischer,  Krankheiten  der  Lymphgefasse,  etc.,   Enke,  Stuttgart,  1901,  p.  104. 


I'RiM./k)   r I  MORS  or  Tin:  i.ymi'ii  (.i..im)s  or  riu:  m-ck    ;;.'>:. 

ot  the  distasf  aiul  its  i  h;ii:KtcJ  as  a  riiiiioi.  I  lusc  considciations 
justif)'  its  inclusion  anion;:,  the  tumors,  althoujih  it  has  had  a  prominent 
place  in  treatises  on  hematolo^w 

Etiology.  All  attempts  to  estahhsh  a  hacterial  origin  for  the  disease 
have  so  far  heen  unsuccessful.  It  is  lejiaided  still  h\  some'  as  tuher- 
culous  m  character,  though  this  \  iew  is  now  j^eneralh'  ahandoned.- 
In  some  ot  tin-  fatal  cases  there  has  heen  e\idence  of  tuberculosis  in 
other  parts  of  the  body,  notahly  in  the  lungs,  and  in  some  of  the  lymph 
glands  typical  tubercles  with  giant  cells  have  been  found.  I'he  likeli- 
hood of  a  double  fallacy  is,  however,  very  apparent;  in  the  Hrst  place, 
a  malignant  lymphoma  ma\  he  the  seat  of  a  secondar\-  tuberculous 
focus;  and  in  the  second  place,  a  purely  tuberculous  glandular  disease 
may  be  regarded  as  malignant  lymphoma.'  Twelve  cases  were  care- 
fully studied  by  hischer  without  any  evidence  of  tuberculosis  being  dis- 
covered. In  some  cases  various  cocci  have  been  found  in  the  blood  and 
lymph  glands,  but  these  also  are  regarded  as  accidental  complications. 
White  and  Proescher^  have  reported  the  discover\-  of  a  spirochete. 

Pathology.-  In  the  early  stages  the  glands  are  usually  soft  though 
their  densit\-  varies  greatly.  On  section,  the  capsule  is  thin;  the  paren- 
chyma is  pink  or  pinkish  gray,  is  semitranslucent,  and  bulges  beyond 
the  cut  edge  of  the  capsule.  At  times,  however,  the  capsule  becomes 
involved  and  the  various  glands  are  more  closeh"  united.  This  occurs 
in  the  absence  of  a  special  excitmg  cause,  such  as  secondar\'  infection 
or  the  v-rays.  The  denser  glands  are,  on  section,  pale  pink,  and  glisten- 
mg,  fibrous  bands  traverse  the  cut  surface  dividing  the  scant\'  paren- 
chyma mto  lobules,  or  in  some  cases  the  entire  surface  ma\'  appear  to 
be  formed   b^"  fibrous  bands. 

An  attempt  has  been  made''  to  divide  the  disease  into  two  forms  on 
the  ground  of  variations  m  densitA".  In  rare  instances  the  glands  attain 
a  large  size  and  are  sclerotic  from  the  first.  Such  cases  are  distinct 
from  the  ordinary  type  of  the  disease,  and  ma}'  well  be  emphasized  b\' 
a  separate  classification.  On  the  other  hand,  the  ordinary  type  varies 
so  much  in  the  degree  of  fibrosis  that  it  is  difficult  to  maintain  a  sharp 
classification.  It  is  a  mistake  to  assume  that  the  small  dense  glands 
are  of  longer  development  than  the  large  soft  ones. 

The  finer  structure  of  these  glands  varies  as  greath"  as  the  macro- 
scopic appearance  would  lead  us  to  believe.      In   the  large  soft  glands 

'  Sternberg,  \  erliand.  d.  deutsche  path,  (iesellsch.,  1904,  p.  128. 

-Dorothy  Reed,  Johns    Hopkins    Hosp.    Rep.,   1902,  x,   13s;  W.  T.  Longcope.   Hull. 
.Aver  Clin.  Lab.,  Penna.  Hosp.,  Philadelphia.  1903. 
'■'  F.  Delafield,  .Med.  Rec,  New  "iork,  1887,  .x.x.xi,  425. 
■*  Jour.  Amer.  Med.  .Assoc,  1907,  xlix,  1988. 
^  Fischer,  loc.  cit. 


356  TUMORS  OF  THE  NECK  AND  CAROTID   TUMORS 

the  lymphoid  elements  are  more  numerous  and  the  endotheHal  cells 
covering  the  septa  are  increased  to  a  slight  extent.  The  lymph  sinuses 
are  filled  with  mononuclear,  polynuclear,  and,  especially,  eosinophilic 
cells, ^  while  the  connective  tissue  is  not  increased.  Finally,  there  are 
present  large  polynuclear  cells  containing  spheroidal  particles  analo- 
gous to  Russell's  bodies  within  their  protoplasm. ^  The  characteristic 
cellular  condition  is  alreadj^  evident  in  the  early  stages,  the  multipli- 
cation of  the  pol3^morphonuclear  leukocytes,  the  proliferation  of  the 
endothelial  cells,  and  the  presence  of  eosinophils  (Fig.  251).     Throughout 

Fig.  251 


-  d 


0 


m  * 


■■{^    "^ 


Hodgkin's  disease:     a,  endothelial  cells;  h,  eosinophiles;  c,  lymphocytes; 
^,  connective  tissue. 

the  progressive  stages,  as  the  glands  become  more  and  more  sclerotic, 
these  same  cells  remain  the  chief  objects  in  interest.  The  lymphocytes 
become  relatively  less  numerous.  The  endothelial  cells  become  more 
numerous  and  also  larger  and  more  irregular,  and  leave  their  position 
at  the  periphery  and  mingle  with  the  other  cells;  their  large  size  and 
irregular  form  and  the  number  of  their  nuclei  make  them  very  striking 
objects. 

In  the  denser  glands  the  interstitial  tissue  predominates.  Trabeculae 
extend  from  the  dense  capsule  into  the  interior  of  the  gland,  present- 
ing an  arrangement  similar  to  the  connective  tissue  m  carcinoma. 
The  cell  types  remain  the  same,  but  the  epithelioid  cells  are  relatively 
more  numerous  and  lie  in  the  meshes  of  the  connective  tissue. 

Glands  of  different  degrees  of  density  often  co-exist  in  the  same 
patient;  although  there  is  a  general  tendency  to  progression  from  the 
softer  to  the  more  dense,  the  relation  is  not  necessarily  a  sequential 
one.      The    glands    show    but    little    disposition    to    undergo    secondary 

1  Goldmann,  Cent.  f.  allg.  Pathologie  u.  path.  Anatomic,  1892,  iii,  665. 

2  Brigidi  and  Piccoli,  Beitr.  z.  path.  Anat.  u.  z.  allg.  Path.,  1894,  xvi,  388. 


rki.M.iKY  II  MORS  ()i   ■/■///■:  DM  I'll  (,i.i\i)s  or  Tin.  m.ck    ;;:.7 


Hodgkin's  disease,  imolving  the  submaxillary  glands. 


Fig.  253 


Hodgkin's  disease,  beginning  in  the  cervical  glancb 


358 


TUMORS  OF   THE  NECK  AND  CAROTID   TUMORS 


changes.  In  fact,  such  changes  are  specifically  denied  b}'  manj^,  but 
in  some  instance  certainly  small  yellow  necrotic  areas  may  be  observed. 
These  areas  differ  from  the  caseated  masses  in  tuberculous  glands  by 
their  canary  yellow  color  and  moist  surface. 

Clinical  Course. — Usually  the  submaxillary  (Fig.  252)  and  cervical 
glands  (Fig.  253)  are  the  first  affected.  Much  less  commonly  the  axillary 
and  very  rarely  the  inguinal  glands  are  the  primary  seat  of  the  disease. 
The  glands  on  one  side  are  usually  enlarged  first,  followed  by  involve- 
ment of  corresponding  groups  of  the  other  side  of  the  body,  and  then 
hy  extension  to  other  groups  (Fig.  254).  This  sequence  is  not  constant, 
however,   and   the  disease  may  remain  localized  m  one  set  of  glands. 


Fig.  254 


Advanced  Hodgkin's  disease,  involving  cervical,  supraclavicular,  and  axillary  glands. 

The  enlargement  proceeds  quickly  without  pain  and  is  usually  un- 
attended in  the  beginning  by  any  constitutional  disturbance.  The 
glands  vary  in  size  from  a  hazelnut  to  an  orange.  It  is  generalh^  stated 
that  the  capsule  is  not  infiltrated,  and  in  any  exception  to  this  the  pro- 
cess is  believed  to  be  inflamrnatory  in  character.  Some  observers  have 
come  to  question  this  statement.  In  a  disease  which  is  characterized 
by  an  increase  of  the  lymphatic  elements  it  is  diflficult  to  prove  that 
when  the  capsule  is  invaded  by  similar  cells  it  is  due  to  inflammatory 
complications. 

In  some  cases  at  any  rate,  the  surrounding  tissue  is  invaded.  Sooner 
or  later,  after  the  primary  group  is  involved,  usually  a  period  of  months, 


I'KiM.iK)    ri  MORS  or  rill:  I.) Mi'ii  (.i..i\i)s  or  riu.  xeck 


:;.■)!> 


anorluM-  f^ioiip  In-^ins  to  cnlar^i-.  I  liis  jii«)U|)  iiins  a  smiilar  l)iir  hv  no 
means  idtiuiial  course  with  rlu-  Hisr  moup;  jr  iiia\  t<|iial  ir  in  si/.c  or 
It  ma\  soon  siii|i;iss  it.  Siinilailv,  otiui  ^^loiips  rna\  Ixcoini-  iinolvcd. 
1  lu-  simouiulin^  tissue-  rt-niaiiis  for  the-  most  part  iiiiattVcfc-d  aiul  sutters 
only  by  compnssion.  I  he  skin  lowrinji;  tlic  cnlai^ccl  j^lands  remains 
unattectcil  l\\  rlu-  disease,  hut  may  hecoiiu  thinned  and  ^loss\'  '  1*  ij^. 
255)  tiom  stretehm^.  and  the  \essels  ma\  hccomc  |ii  omiiunt .  'I'he 
jjlands  may  cause  trouble  b\  compressing;  neighboring  parts,  especiaiU' 
the  bloodvessels  and  nerves,  and  likewise  the  trachea  and  esophaj^us. 


Secondary  nockik-  in  Hodgkin's  disease,  slio\vin<i  the  tliinnc-d  skin  covering  ir. 


After  a  time,  from  a  few  months  to  a  few  years,  the  patient's  health, 
previously  unimpaired,  begins  to  decline.  General  anemia,  cardiac 
v^eakness,  nutritional  disturbances,  followed  b\-  drops\',  are  the  promi- 
nent s^-mptoms.  From  the  exaggeration  of  one  of  these  symptoms  or 
from  some  complication,  the  patient  dies. 


360 


TUMORS  OF  THE  NECK 


Metastasis.  —  The  question  of  metastasis  is  unsettled.  Lymphatic 
nodules  similar  in  structure  to  the  primary  tumors  may  be  found 
in  various  parts  of  the  body,  notably  in  the  lungs,  liver,  and  spleen. 
Whether  these  are  due  to  the  stimulation  of  local  lymphatic  tissue  to 
growth^  by  the  same  noxious  agent  that  produced  the  primary  focus 
has  yet  to  be  determined.  It  is  a  fact,  however,  that  these  nodules 
closely  resemble  the  metastatic  nodules  in  sarcoma,  and  that  they  are 
often  the  most  prominent  factor  in  Hodgkin's  disease  (Ribbert). 

Fig.  256 


Lymphosarcoma  of  the  neck. 

Lymphosarcoma. — This  tumor  is  not  uncommon  in  the  lymph  glands 
of  the  neck.  It  begins  usually  in  the  upper  cervical  (Fig.  256)  or  in 
the  supraclavicular  glands  (Fig.  257),  and  usually  only  one  gland  is 
affected  in  the  beginning.  The  capsule  is  promptly  broken  through 
and  the  contiguous  tissue  invaded;  usually  within  a  few  months  the 
entire  side  of  the  neck  is  covered  by  the  tumor  mass.  Metastasis 
in    distant  organs,  particularly  the  lungs,  takes   place;  but  there  is  no 


1  Borst,  Die  Lehre  f.  der  Geschwulsten,  Bergmann,  Wiesbaden,  1902,  i,  480;  Lubarsch, 
Virchow's  Arch.  f.  pathol.  Anat.,  1906,  clxxxiv,  216. 


J'RI.M  Ik)     T(  M(^kS  or   Till:    DM  I'll   (.l..l\l)S  Ol    Till-:   MiCK     :iiil 

(.hspositioii   toi otiui  <;l;iiul    ;j,it)ii|).s  loliiionir   sccoiulaiih'  imoKccl.      As 
the    ruiiiois   tlc\  (.lop,  rlu'   skin    oltcii  hicoiius    retldenccl,  and    ulceration 


II..  I--,- 


L}mphosarcoma,  beginning  in  the  supraclavicular  glands. 
Fig.  258 


Cross-section  of  a  large  lymph  gland,  from  a  case  of  lymphosarcoma. 


maA-  take  place,  an  accident  usually  anticipated  by  the  physician,  who. 
mistakinii  the  condition  for  an  abscess,  opens  it.     Occasional!}'  a  number 


362  TUMORS  OF  THE  NECK 

of  glands  become  simultaneously  involved,  and  the  surrounding  tissue 
soon  becomes  invaded.  At  the  same  time,  the  cells  change  in  char- 
acter; thev  lose  their  lymphoid  character  and  become  unequal  in  size 
and  often  spindle-form.  These  cases  are  probably  not  lymphosarcoma, 
but  really  varieties  of  Hodgkin's  disease. 

Pathology. — On  section  (Fig.  258)  the  tumor  is  pmk,  soft,  and  pulpy 
when  not  modified  by  the  presence  of  tissue  which  it  has  invaded. 
There  is  a  tendency  to  degeneration.  Microscopically,  it  is  made  up 
of  lymphoid  cells  enclosed  in  a  stroma,  which  is  usually  well  marked. 
The  sections  are  remarkable  for  the  constancy  of  the  cells.  Special 
methods  may  be  required  to  demonstrate  the  stroma. 

Sarcoma  of  the  Lymph  Glands. — These  tumors  rarel}'  occur  in  the 
neck.  They  grow  from  the  connective  tissue  of  the  lymph  glands  and 
not  from  the  lymphoid  cells,  and  have  a  disposition  to  infiltrate  widely 
the  surrounding  tissue.  Spindle-celled,  large  round-celled,  and  even 
giant-celled  varieties  have  been  observed.  They  do  not  differ  from 
sarcomas  elsewhere. 

Differential  Diagnosis. — The  differentiation  between  Hodgkin's  dis- 
ease and  lymphosarcoma  may  tentativel}^  be  proposed  as  follows:  In 
Hodgkin's  disease  there  is  an  enlargement  of  glands  on  one  side  of 
the  body  followed  by  the  enlargement  of  glands  on  the  other  side,  with 
no  sign  of  direct  extension.  The  affected  glands  usuall}^  remain  dis- 
crete, and  some  writers  have  sought  to  make  this  point  the  deciding 
one.  Unquestionably,  however,  the  capsule  may  be  broken  through 
and  the  surrounding  tissue  invaded,  while  the  disease  pursues  other- 
wise a  typical  course.  The  tissue  invaded  may  show  quite  a  different 
cell  tj^pe  from  the  intraglandular  areas.  When  this  complication  occurs 
some  writers  would  exclude  Hodgkin's  disease.  Lymphosarcoma,  on  the 
other  hand,  begins  in  a  single  gland,  early  breaks  through  its  capsule, 
and  invades  the  contiguous  tissue.  Its  course  is  rapid,  often  reaching 
its  termination  in  from  four  to  eight  months.  Distant  metastasis  is 
frequent,  notably  in  the  lungs,  which  are  never  the  site  of  secondaiy 
nodules  in  Hodgkin's  disease. 

The  diffused  swelling,  the  reddened  skin,  and  semifluctuation  often 
lead  to  confusion  of  lymphosarcoma  with  acute  inflammatory  pro- 
cesses, which  is  an  unfortunate  error,  for  the  skin,  if  incised,  does  not 
heal. 

Metastatic  tumors  of  the  neck  may  easily  be  identified  if  the  primar}^ 
tumor  can  be  found.  If  the  glands  are  very  dense  they  should  cause 
one  to  suspect  carcinoma;  in  such  cases  a  small  primary  carcinoma 
of  the  mouth  ma}-^  be  found,  though  often  with  some  difficulty.  Sarco- 
matous metastasis  may  result  from  a  pigmented  mole  in  the  scalp, 
which,  if  found  at  all,  may  show  so  little  change  as  to  escape  suspicion; 


rkiM./k)   ri  .\/nks  or  riii.  dm/'//  <;/../\/as  fj/  ■/■///■:  xj.ck    :3(i:! 

usualh  ,   h()\vc\ti",  siicli   ;i   iiiok-  will   show    si^iis  ot   acnxiry.      Melanotic 
piiiiiuiit  in  rlu-  nurasrasis  nia\    lu-   tiiscti  nihlc-  rhrou^ih  rlu-  intact  skin. 

Ilodukin's  disiasi-  nia\  al\\a\s  In-  clistinjiuislu-tl  lioni  l\  niphatic 
leukemia  h\  the  abscnct-  ol  a  kiikoc)  tic  increase  in  flu-  hNjod  ( I^onj^- 
cope).  Ilu'  liiterniination  of  this  point  with  certainty,  however,  may 
take  se\  (.  ral  examinations  ot  tlu'  hlood  o\ei  a  considerable  time.  1  he 
siiiiieon  ma\,  tluieton',  he  ohlij^ed  to  aiii\i-  at  a  prohahK-  diagnosis 
on   clinical   grounds 

luheiciilosis  ot  tin-  l\  nipli  ulands  otteii  causes  serujus  ditiiculty 
in  differential  diatiiiosis.  In  rlu-  slowly  developing  t3'P^  with  periodic 
remissions,  especially  when  one  or  more  ot  the  glands  show  a  disposi- 
tion to  break  down,  the  difficulty  is  not  so  great.  If  there  is  a  histor\'  of 
recurrent  enlargements  over  a  period  of  se\eral  years  the  diagnosis 
ot  tuberculosis  is  certain.  In  acute  tuberculosis  in  which  the  glands 
of  a  single  group  enlarge  rapidly,  remain  discrete,  and  do  not  break 
down,  a  clinical  diagnosis  may  not  be  possible;  but  the  existence  of 
tuberculosis  elsew'here  in  the  body  mav'  furnish  a  clue.  In  doubtful 
cases  It  ma\   be  necessar\'  to  remove  a  gland  for  microscopic  study. 

Treatment.  In  none  of  these  diseases  has  a  positive  cure  been  re- 
ported. Arsenic  in  the  form  of  Fowler's  solution  has  been  the  drug 
principalh'  employed,  not  onl\'  in  Hodgkin's  disease,  but  in  sarcoma 
as  w^ell.  There  is  no  evidence  that  it  delays  the  course  of  sarcoma,  and 
it  is  difficult  to  estimate  its  value  in  Hodgkin's  disease  because  of  the 
disposition  of  the  disease  to  spontaneous  remissions.  The  same  may 
be  said  of  the  newer  preparations  of  arsenic. 

The  .\-ra\'s  have  been  welcomed  as  a  valuable  means  of  treatment. 
Andrews^  enthusiasticall)'  hails  it  as  having  revolutionized  our  methods 
of  treatment,  and,  indeed,  there  seems  to  be  a  consensus  of  opinion  that 
the  progress  of  Hodgkin's  disease  is  delayed  by  this  means,  because 
large,  soft  glands  disappear  rapidly;  but,  unfortunately,  they  always 
reappear.  Ihe  dense  glands,  as  might  be  expected,  do  not  \'ield  even 
to  this  extent. 

Operative  treatment  has  also  failed  to  effect  a  permanent  cure,  but 
I  now  (1911)  have  had  a  patient  under  observation  for  three  years 
since  the  last  (the  fifth)  operation  with  no  signs  of  recurrence.  In  this 
case  there  was  a  disposition  to  sclerosis  of  the  glands.  In  the  absence 
of  any  other  effective  treatment  it  would  seem  justified  to  subject 
this  t\'pe  of  the  disease  to  radical  operation  when  it  is  confined  to  readily 
accessible  glands.  Such  cases  may  require  not  only  the  removal  of  the 
1\  mph  glands  and  veins,  but  also  the  carotid  artery  and  pneumogastric 
nerve  as  well.     In  the  softer  variety,  too,  when  a  single  group  of  glands 

'  Keen's  .Sur<iery.  .Saunders,  iqo8,  Pliiladeipiiia.  iii.  }20. 


364 


TUMORS  OF  THE  NECK 


is  diseased  and  there  is  no  anemia  indicating  constitutional  disturbance, 
it  is  my  opinion  that  radical  operation  is  the  proper  course  to  pursue. 
Years  of  freedom  may  be  secured  before  another  group  becomes  affected, 
and  that,  too,  may  be  removed.  By  radical  operation  must  be  under- 
stood the  removal  of  all  tissue  which  may  harbor  glands  either  normal 
or  diseased.  The  removal  of  onh^  obviously  diseased  glands  is  never 
justified. 

CARCINOMA   OF   THE   NECK 


Carcinomas  of  the  neck  may  be  primary  or  secondary.     The  primary 
maA'  be  of  the  skin  or  of  the  vestigial  remains  of  the  gill  clefts. 


Fig 


Basal-celled  epithelioma  of  the  neck. 
Fig.  260 


Basal-celled  carcinoma  of  the  supraclavicular  region. 

Primary  Carcinoma. — Carcinoma  of  the  Skin. — The  skin  of  the  neck, 
especiall}/  in  the  region  of  the  ear,  is  not  infrequently  the  seat  of  basal- 
celled    epitheliomas    closely    resembling    those    of   the    face    (Fig.    259). 


C.IRCISOM.I  or  rilE  MICK 


365 


Kic.  261 


Deep  carcinoma  of  rlie  neck. 
Fig.  262 


^ 


tt. 


\ 


Epitluhonn  nt  nt(.k    cancer  nests  in  the  Iowli,  In  p..rrroplned  sebaceous  glands 
ar  the  upper  |iarc  of  tlic  hL:urc. 


366 


TUMORS  OF  THE  NECK 


Often  they  are  multiple.  These  usually  arise  from  seborrheic  patches, 
rarely  from  papillomas.  Typical  basal-celled  carcinomas  of  the  clavic- 
ular region  also  sometimes  occur  (Fig.  260).  In  the  same  region  the 
more   destructive   type   (Fig.    261)   of  epitheliomas   may   occur.     These 

Fig.  263 


J^^-. 


Thyroglossal  carcinoma  of  neck. 

are  similar  in  their  course  to  those  of  the  Up  (Fig.  262);  the  deeper 
structures  of  the  neck  are  quickly  invaded  and  lymphatic  metastasis 
follows  early.  The  diagnosis  is  that  of  similar  lesions  elsewhere,  and 
the  treatment  is  excision.      In  the  deep  type  wide  excision  should  be 


sr.cfjxi)  iR)-  T I  MORS  or  rill-  m.ck  3(»7 

tollowiil  In  ixtii  p;i  t  loll  ot  both  antiiioi  :iiul  postci  loi  <;i()U|)s  ot  r(.i\K;il 
ulaiuls   III    all   (.'ases. 

Branchiogenic  Carcinoma.  C'aic  inoiiias  occasionally  arise-  from  rlu-  rc- 
iiiaiiis  of  ml!  cltlrs.  usiialh  ilu  second.  I  hc\'  occur  most  trecjucnriy 
III  a<;c'cl  knialcs.  Ilu\  toi  ni  delist  liimois  situated  heiieatli  rhe  tascia 
anteiioi  to  and  Inlow  the  st  ernomasioid  miisele  i  I' ifi.  2^31,  rhou^li  the 
lowc-i  pornon  ot  tlu'  luik  is  soimtinies  afhited.  I  lu-\'  are  artcndcd  by 
se\'ere  pain,  winch  is  often  nfeireil  to  the  eai,  and  nia\  he  telt  before 
tin-  riinior  IS  tlisco\cred.  I  lie\  an-  adiurenr  to  the  deeper  tissues  of  the 
neck. 

Diagnosis.  The  location,  the  density,  and  rhe  notlulation  of  the 
surface  make  a  characteristic  picture.  I  hey  must  he  distinguished  from 
metastases  of  primar\  carcinoma  of  the  mouth  and  especially  of  the 
larynx,  where  small  tumors  are  often  oxerlooked.  These  secondary 
tumors  are  more  spherical  or  ovoid  in  outline  and  lack  the  small  dense 
excrescences  of  a  primai\'  tumor.  Sarcomas  of  the  neck  are  softer. 
Carcinomas  of  aberrant  th\r()id  <:;lands  which  simulate  branchiogenic 
carcinomas  have  been  reported;  they  can  be  distinguished  only  by  a 
microscopic  examination.  luberculous  masses  may  give  the  general 
outline  of  carcinoma,  but  their  densit}'  is  distinctne. 

Treatment. — A  single  case,  that  of  Eigenbrodt,'  has  been  reported  in 
N\  hich  the  patient  was  well  two  \ears  after  operation.  Radical  removal 
IS  indicated  in  ever}'  case  when  possible;  no  other  treatment  has  any 
eflect.  It  has  been  recommended  that  all  the  vessels,  together  with 
the  vagus  and  sympathetic  nerves,  should  be  removed.  Rapid  recur- 
rence is  the  rule. 


SECONDARY   TUMORS    OF    THE    NECK 

The  presence  of  a  tumor  of  the  neck  should  always  suggest  the  possi- 
bilit}-  that  it  is  secondare  I  sualh'  this  is  easily  determined  b}'  search- 
ing for  a  primar\-  tumor  in  the  regions  drained  by  the  afterent  lymphatics 
of  the  diseased  glands.  Sometimes,  however,  the  primary  tumor  is 
so  situated  that  it  is  easih'  overlooked.  lumors  which  metastasize 
in  the  l\mph  glands  are  in  a  very  large  proportion  ot  cases  carcinomas, 
but  occasionall}',  sarcomas  also  have  secondary  growths  in  the  lymph 
glands. 

Secondary  Carcincma  of  the  Neck. — The  first  sign  of  a  metastatic 
lymph-gland  carcinoma  is  a  hard,  bean-like  nodule  deep  in  the  tissues. 
When  small   it  can   be   palpated   only  when   the  overlying  muscles  are 

'  I^eiirscli.  (Jesellsch.  t".  Chir..  1804,  wiii.  138. 


Fig.  264 


%  % 


Metastatic  carcinoma  of  the  submaxillary  glands,  appearmg  after  an  undiscovered 
carcinoma  of  the  floor  of  the  mouth. 


Fig.  265 


Cervical  lymphatic  involvement  appearing  after  a  lip  carcinoma  had  been  removed. 


xA'coA /)  /A')   ri  MOMS  or  riir.  mu:k  3(i9 

nhixicl;  in  tlu-  suhimin.il  ^ll)lll>  1)\  sli;;htl\  dioppiiii;  tlu-  (.hiii,  in  rlu- 
suhiiKixilhii  \  ;in(l  cervical  jiioup  by  passively  inclininj;  the  head  to  the 
side  exaniuu'd.  As  the  nodule  ^rows  larger  it  remains  dense  and  often 
retains  a  sharp  outinu',  hiii  it  is  iisualK  not  ticeU  moNahle,  heinj^  asso- 
ciati'd  mtimatilv  with  lui^hhonni;  glands.  I  his  loss  ot  mol)iIit\  occurs 
before  the  niali^nanr  cells  peiforate  the  capsule,  and  results  troni  a 
reactive  piohtiiarion  ol  the  connecti\'e  tissue.  When  the  capsule  is 
intiltratctl,  which  may  not  occur  until  rlu-  uland  is  as  larj^e  as  a  hickor\- 
nur  or  larger,  the  gland  pockets  and  surrounding  tissue  become  fused 
into  a  solid  mass  (Figs.  264  and  265).  It  is  often  difficult  to  determine 
whether  the  mass  is  formed  by  a  diffuse  growth  of  the  carcinoma  oi 
from  the  coniuctn  e-tissue  proliferation.  I'sualh'  the  latter  is  the  case. 
When  malignant  cells  have  escaped  from  the  glands  small  dense  nodula- 
tions  can  be  palpated  upon  the  surface  of  the  mass.  While  the  carci- 
noma cells  are  still  confined  to  the  glands  a  more  rounded,  though 
often  bosselated,  mass  of  characteristic  hardness  results.  The  secondarv 
tumor  ma}'  serioush'  interfere  with  deglutition  or  respiration,  and  the 
deep  nerves  may  become  invaded.  Metastases  in  this  region  are  hable 
to  central  degeneration,  which  tends  to  gain  the  surface  and  result  in 
crateriform  openings,  which  lead  to  suppurating  cavities.  These  con- 
ditions are  hastened  by  secondar}'  infection  from  the  mouth.  The  infec- 
tion may  spread  to  the  deeper  tissues  of  the  neck,  producing  suppuration 
about  the  esophagus  or  in  the  mediastinum,  or  the  necrotic  process 
ma}'  open  a  vessel  and  cause  hemorrhage. 

Diagnosis. — Usually'  the  primar}'  growth  is  apparent  and  the  nature 
of  the  neck  tumor  is  evident.  Rarel}'  the  primary  tumor  is  small  and 
inaccessible,  as  in  the  laii'nx  or  esophagus;  or  the  primar\'  tumor  ma\" 
have  been  removed  jears  before,  leaving  nothing  but  a  scar.  When 
careful  search  fails  to  reveal  an}'  trace  of  such  a  tumor,  the  carcinoma 
of  the  neck  is  probabh'  branchiogenic. 

Prognosis. — In  secondai}-  carcinoma  of  the  neck,  when  the  primary 
tumor  has  been  untreated,  radical  operation  ma}'  offer  some  hope  of 
prolongation  of  life  or  even  cure.  When  the  primary  tumor  has  been 
removed  the  disease  has  been,  in  my  experience,  invariabh'  fatal.  Radical 
operation  possibh'  dela}'s  the  progress  sometimes;  quite  as  often,  and 
certainl}-  when  carcinoma  cells  have  escaped  the  gland  capsule,  it  hastens 
the  course  of  the  disease. 

Treatment. — No  other  problem  confronts  the  surgeon  so  often  as  the 
recent  enlargement  of  cervical  glands  following  a  }ear  or  two  after 
local  excision  of  a  small  tumor  of  the  lip  or  tongue.  The  famih'  ph}- 
sician  urges  radical  operation,  and  the  patient  consents.  When  the 
growth  is  limited  to  the  glands  and  is  not  spread  diffuseh'  throughout 
the  tissue  nor  attached  to  the  carotid  sheath,  esophagus  or  trachea, 
24 


370  TUMORS  OF  THE   NECK 

the  operation  is  technicalh^  possible.  If  the  removal  of  the  common 
carotid  artery  and  the  deep  nerves  would  be  required,  or  if  the  esophagus 
or  trachea  was  involved,  the  disease  is  inoperable.  If  cachexia  or  gland 
suppuration  is  present,  the  condition  would  best  be  let  alone.  The  local 
use  of  acetone  ma}"  lessen  the  odor  from  ulceration  and  perhaps  delay 
the  progress  of  the  disease.  When  the  larynx  becomes  invaded  or 
the  trachea  compressed,  tracheotom}"  may  be  required.  When  the 
esophagus  becomes  occluded,  gastrostomy  may  add  a  few  days  to  the 
existence  of  the  patient,  though  it  is  questionable  in  this  case  if 
the  better  treatment  is  not  to  use  morphine  as  a  diet. 

Secondary  Sarcoma  of  the  Lymph  Glands. — Pigmented  moles  of 
the  temple,  scalp,  or  face,  melanomas  of  the  eyes,  and  more  rarely  sar- 
comas situated  elsewhere  on  the  head,  give  rise  to  secondary'  tumors 
of  the  Ij^mph  glands.  In  this  respect  they  vary  from  the  sarcom.a  t3"pe, 
though  they  are  usuall}/^  classed  as  sarcomas.  In  their  course  the}' 
resemble  carcinomas  more  than  sarcomas,  which  recalls  the  wisdom  of 
Ribbert^  in  grouping  these  tumors  separately  under  the  head  of  mel- 
anomas. They  form  nodules  within  the  glands,  which  are  more  or  less 
discrete  at  first,  but  which  fuse  later.  Usuall}'  metastases  elsewhere 
terminate  the  life  of  the  patient  before  the  growth  in  the  neck  causes 
much  discomfort. 

Diagnosis. — The  pigment  can  often  be  seen  through  the  unopened  skin, 
and  the  discovery  of  the  primar}"  tumor  establishes  the  diagnosis.  The 
softness  of  the  glands  differentiates  them  from  carcinoma.  Explora- 
tory excision  should  be  avoided. 

Treatment. — Operation  is  worse  than  useless,  and  no  means  is  known 
that  will  sta}'  the  progress  of  the  disease. 


CYSTIC    TUMORS 

Lymphatic  Cysts  (Hydrocele  of  the  Neck). — These  are  congenital 
dilatations  of  the  lymph  channels  and  occur  in  those  regions  where  the 
l}^mph  channels  are  first  formed  in  the  embr}^o.  They  are  usuall}^  situ- 
ated immediately  above  the  clavicle  (Fig.  266),  but  they  may  be  found 
on  the  chest  or  in  the  axilla.  The}^  are  soft  and  }'ielding,  their  walls 
being  composed  merel}"  of  a  delicate  endothelium.  They  may  remain 
nearly  stationary  or  they  may  grow  with  some  rapidity.  The}'  are 
attached  to  the  surrounding  tissue,  and  can  usuall}^  be  demonstrated 
to  originate  deep  under  the  clavicle. 

They  sometimes  disappear  spontaneoush',  the  fluid  becomes  absorbed, 

Geschwiilstlehre,  Cohen,  Bonn,  1904. 


CYSTIC   77  .UOA'.S 


:i7i 


aiul  rlu-  walls  colhijisi-.  Hicaiisc-  of  rluir  cka-p  ;it tachiiunr  ;il<jn^  the 
large  vessels,  operative  removal  shoulcl  be  umlei  taken  onl\  when  some 
complication  ensues.  Jordan  advises  puncture  and  injection  with  iodine. 
Thev  ma\  he  incised  and  packed,  hut  troublesome  infections  may  com- 
plicate  this   form   ol    rrearnuiu. 


Kk;.  266 


L\  niphatic  cysts  involvinir  the  neck  and  axilla. 

Blood  Cysts. ^Blood  cysts  in  the  neck  have  been  observed  which 
resulted  from  a  developmental  anomah"  of  the  subclavian  vem  or  ot 
the  internal  jugular  vein,  or  from  hemorrhage  into  a  branchial  cyst.' 
In  many  instances,  the  exact  etiolog}'  cannot  be  determined;  some  cysts 
retain  communication  with  a  vein.  The  blood  is  fluid,  and  trequenth- 
remains  so  for  an  indefinite  time  when  drawn.  The  structure  ot  the 
wall  in  some  instances  resembles  closely  that  of  a  vem.  About  one- 
si.xth  of  them  are  congenital.  They  are  globular  tumors  of  the  lateral 
aspect  of  the  neck,  are  smooth,  soft,  fluctuating,  and,  when  m  com- 
munication with   a  vessel,  compressible. 

The  diagnosis  when  the  cysts  are  compressible  is  easy.  \\  hen  there 
is   no  communication   with   a   vein   puncture   is   the  best   aid    to  difFer- 

1  Franke,  Deutsch.  Ztschr.  f.  Chir..  18S8.  xxviii.  411. 


372  TUMORS  OF  THE  NECK 

entiation  from  other  tumors  with  which  they  may  be  confused,  namely, 
branchiogenic  and  lymph  cysts,  angiomas,  aneurj^sms,  lipomas,  and 
medullary  carcinomas. 

The  treatment  has  been,  first,  puncture,  with  or  without  the  injec- 
tion of  iodine;  second,  incision  with  packing;  third,  excision.  Iodine 
must  not  be  injected  if  there  is  a  possibilit\'  of  communication  with 
a  vessel.  Excision  is  the  treatment  of  choice,  but  an  extensive  opera- 
tion is  required  and  is  not  to  be  lightly  undertaken.  Kaczanowsk}^^ 
succeeded  in  curing  a  case  by  simple  compression  with  a  flannel  bandage. 

Branchiogenic  Fistulas. — In  the  involution  of  the  gill  clefts  sometimes 
one  of  them  fails  to  close  and  a  sinus  results.  It  is  now  generally  believed 
that  it  is  alwaj's  the  second  which  is  at  fault.-  The  inner  opening  of 
the  fistula  is  near  the  tonsils  or  in  the  pharynx  in  the  region  of  Rosen- 
miiller's  fossa.  The  outer  opening  is  less  constant,  but  is  usuall}'  in  the 
anterolateral  region  of  the  neck  in  front  of  the  sternomastoid  muscle 
and  below  the  hyoid  bone.  It  may,  however,  be  remote  from  this,  and 
is  sometimes  in  the  median  line.  Notwithstanding  the  variable  posi- 
tion of  the  cutaneous  opening,  the  anatomical  relations  of  the  tract  are 
constant.  Traversing  the  skin,  subcutaneous  tissue,  and  platysma,  it 
passes  upward  through  the  deep  fascia  to  the  great  horn  of  the  hyoid 
bone,  ascends  between  the  external  and  internal  carotids  and  reaches 
the  pharynx  by  passing  the  posterior  belly  of  the  digastric.  It  is  usually 
lined  in  the  lower  portion  with  squamous  epithelium  and  in  the  upper 
portion  with  ciliated  columnar  cells,  but  the  entire  tract  may  be  lined 
with  one  or  the  other  type  exclusively;  there  may  be  an  extension  down- 
ward of  the  ciliated  epithelium  of  the  upper  portion,  or  the  original 
columnar  epithelium  of  the  upper  portion  may  become  transformed 
into  squamous  epithelium.  When  the  latter  transformation  has  taken 
place  it  is  manifested  by  the  presence  of  lymphoid  follicles  in  the  wall, 
a  certain  indication  that  the  part  of  the  tract  so  surrounded  is  derived 
from  the  inner  portion  and  is  of  entodermal  origin. 

Usually,  a  branchiogenic  fistula  is  large  enough  only  to  admit  a  fine 
probe,  but  rarely  it  may  be  so  large  that  food  passes  through  it.  Their 
discussion  is  of  importance  in  a  treatise  on  tumors  because,  in  the  first 
place,  they  are  frequently  incomplete  and  by  the  collection  of  their 
secretions  form  cysts;  in  the  second  place,  the  persistence  of  epithelial 
tissue  sometimes  gives  rise  to  carcinomas  deep  in  the  neck  which  are 
otherwise  inexplicable. 

Branchiogenic  Cysts. — Cysts  derived  from  the  closure  of  the  fistulas 
above  described  are    sometimes    observed   and   may  correspond   to  the 

1  Deutsch.  Ztschr.  f.  Chir.,  1897,  xliv,  409. 

2  Hildebrand,  Arch.  f.  klin.  Chir.,  1894,  xUx,  167;  F.  Koenig,  Arch.  f.  khn.  Chir.,  1896, 


C)  STIC    ri  MORS  ■^"> 

ciuiic-  CDinsf  of  tin-  caniil  ..i  to  ;.n\  i>oi  t.oii  of  ir.  TIk->  arc  usually  found 
anterior  to  tlu-  sttrnoniastoid  (Figs.  z(>7  and  268),  but  wlu-n  larjic  they 
occupy  tlie  entire  lateral  n-ion  of  tin-  neck.  They  are  usually  sniffle, 
bur  mav  be  nuilrilocular.  Ilu-  skin  over  tluni  is  usuallv  unchantitd 
:,iul  frrcl\  iiiovabK.  1  he  \  arc-  usually  more  or  less  rt.xed  on  the  deep 
aspect  to  the  vessel  sheath,  rlu-  h\ oid  bone,  or  in  the  region  of  the  styloid 
process.     As  above  indicated,   the\    ma\    be  lined   with   .s(iuamous  epi- 

Fui.  z(>7 


Branchiogenic  c\  sr. 

thelium  when  derived  from  the  lower  part  of  the  duct  or  when  a  trans- 
formation of  the  columnar  epithelium  to  this  form  has  taken  place  in 
the  upper  part;  or  b\  columnar  epithelium  when  derived  from  the  pharyn- 
geal end   of  the   duct. 

The  presence  of  1\  mph  follicles  in  the  walls  indicates  an  origin  trom 
the  upper  portion,  no  matter  what  the  character  of  the  lining  epithehum 
may  be  (Fig.  269).  When  the  cysts  are  lined  with  squamous  epithelium 
they  may  contain  hair  and   skin  glands.      The  contents    depend    upon 


374 


TUMORS  OF  THE  NECK 
Fig.  2( 


Branchiogenic  cyst. 
Fig.  269 


\ 


"y  *-'/" 


Gill  cleft  cyst:    a,  area  covered  with  flat  epithelium;  h,  area  of  squamous  epithelium 
forming  papillary  projections. 


CYSriC  TLMORS 


375 


rlu-  oiif^iii;  wlun  liiud  l>\  (.oluinnar  r|>irlulium  tlu-)  ait-  usikiIIv  clomly 
ami  imuiiious.  Inn  ina\  In-  siious;  when  liiucl  h\-  cpiclcrnia!  tissue 
then'  arc  tlciiiionl.  I  his  variation  in  tontiius  has  led  to  classiHca- 
tion  into  serous,  arluioniatous.  anti  ciernioiclal  t\pes  an  unfortunate 
moupinu,  since  it  confuses  iheni  with  tiniiois  of  (iitterent  etioloji;y. 

rhe\  are  likeh  to  he  confused  with  cysts  of  other  origin,  chieHy 
hniphangionias  and  c\  sts  of  ahenant  thyroids.  From  the  former 
they  can  usuall\'  be  distin^;uished  by  their  tenser  walls,  and  from  the 
latter  In  the  ditteienr  points  of  attachnient.  Aspnarion  nia\'  be  of 
service.      Slo\\l\    dc\  elopinii;  abscesses  may  smuilate  them.       I  he  history 


1  h3Toglossal  cyst. 

of  the  case  is  frequently  of  service.  Wens  in  this  region  are  distinguished 
by  a  closer  association  with  the  overlying  skin  and  by  the  absence  of  a 
deep  attachment.  The  diagnosis  may  be  complicated  by  the  presence  of 
other  tumors  in  their  walls;  lymphomas  or  lymphangiomas  may  develop 
in  the  adenoid  tissue,  or  the  cyst  wall  ma\-  become  carcinomatous. 

Opening  and  draining  the  sac  is  uniformly  followed  b\'  fistula,  and 
removal  is  often  hazardous  because  of  the  intimate  connection  of  the 
wall  with  the  bloodvessels.  The  latter  course,  however,  should  always 
be  undertaken,  and  if  association  with  the  veins  is  intimate,  these  may 
be  resected.     If  the  cyst  is  inseparably  attached  to  the  carotid,  a  por- 


376 


TUMORS  OF  THE  NECK 


tion  of  the  cyst  wall  should  be  left  and  the  epithelium  destroyed,  so  as 
to  secure  obliteration  rather  than  face  the  mortalit)^  incident  to  ligation 

Fig.  271 


Wen  of  the  neck 
Fig.  272 


Retro-aural  dermoid  in  man,  aged  twenty-six  years. 

of  this  vessel.     Cases  in  which  the  cyst  wall  has  been  removed  have 
resulted  in  recovery. 


CYSTIC  -nMORS 


:Vi 


Thyroglossal  Cysts  il'ij;.  2701.  Nm  mln  ijiu  m  l\  tin-  mioMiiriiitcd 
rc'iiKiins  ot  the  t  h\  roj»;l()ss;il  dint  ^i\f  iisr  to  cyst  toiiiKirioii.  I  lu\  In- 
ahow  tlu-  h\()icl  hone,  at  ilu-  tlooi  ot  the  nioiirli,  01  at  rhc  base  of  tin- 
tonmic.  I  lu'\  iiuist  In-  dist mmiisluil  lioin  ilciinouls  aiul  lipomas  iii 
tins    ictiioii. 

Wens.  SrhatH-oiis  i-\  srs  an-  not  iiif r((|iuiirl\  {omid  111  rhc-  neck. 
I  heir  !j,l()hiihir  toiiii  ami  intiniatt-  ulatioii  to  the  skin  arc  suHicicnt 
to   idciUity    t  hi  111    I  1'  1^.    zyi  ). 


k;.  27 


Dernidid  of  the  suhnia\illar\'  region. 


Dermoids. — Both  lateral  and  anterior  regions,  particularly  above 
the  mastoid  (Fig.  272)  and  above  the  hyoid  bone,  are  sometimes  the 
seat  of  dermoids  (Fig.  273).  They  usually  begin  to  develop  slowly 
about  the  time  of  puberty.  Their  freedom  from  attachment  to  the  skin 
differentiates  them  from  wens,  and  the  lack  of  attachment  to  deeper 
structures  prevents  confusion  with  c\  st  formation  in  vestigial  ducts. 


378 


TUMORS  OF  THE  XECK 


SOLID    BENIGN    TUMORS    OF    THE    NECK 

Lipomas. — The  neck  is  one  of  the  chief  sites  for  Hpomas.  They 
appear  most  frequenth'  on  the  back  of  the  neck  (Fig.  274J,  not  so  fre- 
quenth'  on  the  sides  (Figs.  275  and  276),  and  still  less  frequently'  m 
front  TFig.  277).  The}'"  appear  here,  as  elsewhere,  as  soft,  lobulated, 
circumscribed    tumors,   free   both   from   the   skin   and   from   the   under- 


FiG.  274 


Fig.  275 


Lipoma  of  the  neck. 


Lipoma  of  the  submaxillary  region. 


lying  structures.  They  are  painless  unless  the}'  press  upon  nerves; 
when  deeph'  seated,  the}'  ma\-  cause  pain  in  the  area  of  distribution 
of  the  brachial  plexus.  Their  mobility  ma}'  be  limited  if  the}'  are  situ- 
ated under  immovable  structures.  In  the  lateral  regions  of  the  neck 
they  may  extend  under  the  sternomastoid  and  the  trapezius,  and  hence 
ma}'  not  be  accessible  for  examination. 

Diagnosis. — When  situated  on  the  side  of  the  neck  lipomas  may  be 
mistaken  for  carotid  tumors,  but  their  mobilit}'  upward  serves  to  differ- 
entiate them,  carotid  tumors  being  immovable  in  this  direction.     They 


SOLID  iii:\n;\  ri  mors  or  the  ma.k 


;i7!» 


ail-  iisualh  situaiid  luhiiul  oi  Ixlow  rlic  (.aiDtuI  hitiiicatioii.  Their 
sottiuss  IS  siirticuiir  to  clirtciiiuiatc  tluni  hom  tin-  various  I\  inph  ^laiul 
iii\()I\cnuMrs  111  tins  nt^ioii.  Deeply  seated  cysts  nia\'  |")ieseiit  the 
pseudoHiuruation  ot  li|)onias,  l)ur  hponias  ate  rareh'  jilohular,  as  are 
c\  sts,  ami  deeply  siatttl  lijioiiias  iii  the  ic^ion  ot  ^dl  (.left  c\'sts  are 
rare.  Lymph  c\sts  occur  in  eail\  Idt,  and  rlu-  hhiish  loloi  ot  rlu- conreiirs 
can  otten  In-  peiceixi-d  rliroiiiih  rlu-  skin. 


l-'ic.  276 


I  I.,. 


Lipoma  of  the  supraclavicular  fossa. 


Lipoma  of  the  submental  region. 


Treatment. —  1  he  treatment  here,  as  elsewhere,  is  removal.  The 
lobulations  are  likel\-  in  this  region  to  extend  under  important  struc- 
tures, and  care  must  be  exercised  in  their  removal.  Because  of  the 
deep  cellular  tissue  open  drainage  should  be  employed  for  a  few  days. 

Fibromas.^ — "Rankenneuromas"  of  the  subcutaneous  tissue  are  some- 
times observed,  but  do  not  differ  from  those  situated  in  the  region  of 
the  temple.  Dense  tibrous  tumors  are  sometimes  found  in  the  deeper 
portion  ot  the  neck,  most  frequently  in  the  lateral  and  posterior  parts. 
They  spring  from  the  deep  fascia,  and  their  density  and  smoothness 
distinguish  them  from  tumors  which  they  otherwise  resemble.  Because 
of  their  deep  attachments  extensive  operations  are  required  for  their 
removal. 

Congenital  Chondromas. — A  number  of  congenita!  tumors  composed 
wholly  ot  cartilage  have  been  described  in  the  neck.'     The\'  are  with- 


'  Zahn.  \  irchow's  Arch.  f.  path.  .Anat.,  1889,  c.w,  47. 


380 


TUMORS  OF  THE  NECK 


out  practical  significance.     Teratomas  have  been  found,  but  are  of  theo- 
retical interest  only.^ 

Tumors  of  the  Hyoid  Bone. — Chondromas  of  the  hyoid  bone  have 
been  reported,  though  they  are  very  rare.'-  A  case  of  this  kind  operated 
upon  by  J.  W.  Perkins  is  represented  m  Fig.  278. 

Fig.  278 


Chondroma  of  the  hyoid  bone. 


TUMORS    OF   THE    THYROID 


The  common  enlargements  of  the  thyroid,  the  goitres,  are  not  true 
tumors,  and  an  extended  consideration  of  them  is  not  required  here. 
The   thyroid   gland   is,   however,   subject  to   true  neoplastic  formation. 

Adenomas. — Two  classes  of  adenomas  have  been  described — the 
fetal  and  the  tubular.  The  former  is  congenital,  and  appears  at  or  soon 
after  birth  as  a  single  or  multiple  nodulation.  In  structure  it  resembles 
the   undeveloped    gland,    being   form.ed   of  tubules   with    low   columnar 

1  Pupovac,  Arch.  f.  klin.  Chir.,  1896,  Hii,  59. 

^  Spisharny,  Deutsch.  med.  Wochenschr.,  1892  xviii,  853. 


re  MORS  or  riii:  rin  koid 


:i8i 


(.J)!!  lulium  ami  a  !aiii,<  iiiiinlx  i  ol  MoocK  cssi-ls.  I  lie  tiihiihir  upi- 
closeh'  itsciiiM(  s  ilu  Ilia!  loini  in  stiiuruic  '  1' in.  279)  ami  clitters 
cliiifl\'  in  its  soimw  hat  ^itarci  tciultiu')'  to  fiiowth.'  It  forms  a  solid 
circunisd  ilHcl  tumor,  iisiiall)'  ot  slow  growth,  riic  piesc-iicc  oi  adenomas 
in  tin-  th\  loid  is  iasil\  detected  h\  the  cxcinsions  they  make  during 
di«;liititi()li.       Ilu\    nia\    lie  leadlh    enuelcated. 

Fig.  279 


Adenoc\stic  thvroid  <ilancl. 

Thyroid  Cysts. —  In  man\'  goitres  portions  of  the  thyroid  show  vary- 
ing degrees  of  c\st  formation.  Sometimes  c^sts  arise  from  single  or 
multiple  cavities  in  benign  struma  and  from  globular  tumors  in  one 
pole  of  the  gland  (Fig.  280).  They  are  lined  with  a  single  layer  of  cuboid 
epithelium  (Y\g.  281),  and  are  filled  with  colloid  material  or  sometimes 
with  a  straw-colored  fluid  resulting  from  old  hemorrhages. 

Carcinoma. — Carcinoma  of  the  th3roid  is  alwa\s  preceded  by  benign 
struma.  It  appears  slightly  more  often  in  females  than  in  males  and 
usualh-  between  the  fortieth  and  fiftieth  years,  though  sometimes  before 
or  after  this  period.  Trauma,  pregnancy,  and  infection  have  been 
regarded   as  causes. 

Pathology. — They  are  usually  adenocarcinomas.  1  he  cells  invade 
the  surrounding  tissue  and  fill  the  lumen  (Fig.  282).  Less  malignant 
forms    retain    the    gland    formation,    form    papillary    growths    into    the 


1  Wolfler,  Arch.  f.  klin.  C'hir..  1883,  xxix,  7S\- 


382 


TUMORS  OF  THE  NECK 


lumen^    and    sometimes    give    rise    to    proliferating    cysts.      Sometimes 
squamous-celled    tumors    which    are    supposed    to    originate    from    the 

Fig.  280 


Cyst  of  the  thyroid  gland. 
Fig.  281 


."•-■;  '^;•;^^;; 


-  JMi. 


M. 


Cystic  goitre. 


TUM(JRS  fJl    Till.    I'll)  Roll) 


383 


rli\i()t!,l()ss;il   tliKt    ;in-  I  luoiinicnil.      (  )n   scctiDH,  tli(\    \\w  ^r;i\isli  \sliiii- 
or  \  cllow  isli  i!,r:i\  ,  con  ri;i  stint;  with    tin    pmk    1 1  ;i  iisliucnt   :ip|H;ir;inc(.-  of" 


I'k;.  2H: 


r..»- 


Cilobulai"  carcinoma  of  the  tin  roitl  iilaiul 

the   normal   gland.       I'hey  occiip\-  more  or  less   the  site  of  the   thyroid, 
and  vary  m  size,  sometimes  being  so  large  as  to  cover  the  entire  side 


384 


TUMORS  OF  THE  NECK 


of  the  neck  and  sometimes  so  small  that  they  are  discovered  only  by 
accident  in  the  course  of  an  examination  of  supposedly  simple  struma. 
Sometimes  their  surface  is  smooth  (Fig.  283),  sometimes  irregular 
and  bosselated  (Fig.  284).  In  consistency  they  may  have  the  usual 
carcinomatous  hardness,  but  more  often  they  are  soft  and  non-resistant, 
sometimes  semifluctuating.  Frequently  the  skin  is  affected  either 
directly  by  the  growth  or  merely  discolored  by  the  prominence  of  the 
vessels. 

Fig.  284 


Carcinoma  of  the  right  lobe  of  the  thyroid  gland. 

Clinical  Course. — Usually  the  first  manifestation  of  these  tumors  is 
the  sudden  enlargement  of  a  previously  existmg  struma.  This  may 
be  discovered  b}^  the  increase  in  size,  but  usually  there  are  certain  sub- 
jective conditions  which  call  attention  to  the  change  in  character. 
Pain  extending  across  the  neck  into  the  chin  or  toward  the  ear  or  occiput 
appears.  These  pains  must  be  ascribed  to  the  irritation  of  the  nerves 
within  the  capsule  due  to  its  distention,  for  they  appear  before  the 
capsule  is  broken  through.  This  must  be  regarded,  therefore,  as  one 
of  the  early  signs. 

After  the  invasion  of  the  capsule  the  surrounding  structures,  the 
muscles,  and  lymph  glands  (chiefly  the  jugular)  are  involved.  The 
veins  in  the  adjacent  territory  become  involved  by  thrombosis  or  by 
direct  growth  of  the  tumor  into  them.     From  this,  edema  of  the  face 


re  MORS  (J  I  THE  r//)  ko/n  ;isr> 

;iiul  luck.  oi  i\(  II  hiiakini;  down  of"  tumors,  ma\  icsult.  '|'lic  nerves  are 
ofttii  iii\()l\icl  i;irl\  ;  rlu-  iii\:ision  of  r lie  rctiinciis  ma\  cause  paralysis 
of  tin-  cortls,  compression  of  tlie  vafii  ma\-  be  expressed  as  pain  in  the 
sromach,  and  in\()l\ement  of  the  s\inpatheric  h\-  vascular  disturbance 
ami  dilatation  of  the  pupils.  As  the  tunior  ^rows  larger,  compression 
of  the  trachea  and  esophagus  or  ulceration  into  them  nia\  result.  When 
the  Ulterior  of  the  rumor  softens  there  ma\  be  fever,  though  withf)ut 
an  mfection. 

Metastasis.  I  lure  has  been  a  controversy  as  to  the  possibilit\-  of 
a  normal  gland  producing  metastasis.  It  has  occurred  in  glands  with 
slight  malignanc\  ,  and  those  cases  in  which  metastasis  has  occurred 
from  supposedly  normal  glands  probably  belong  to  this  class.  In 
carcinoma  of  the  thyroid  metastasis  occurs  relativeh"  earl\-  and  in  the 
majority  of  the  cases  aftects  the  lungs  first,  and  ne.xt  in  frequency-  the 
hver,  bones,  kidneys,  suprarenal  bodies,  and  brain."  Metastasis  may 
occur  so  early  that  the  secondary  tumor  is  regarded  as  primary. ^  This 
indicates  the  importance  of  suspecting  the  th3roid  whenever  obscure 
epithelial  tumors  occur  in  regions  where  epithelium  does  not  normally 
occur. 

Diagnosis.— A  struma  hitherto  quiescent  in  a  person  be\ond  the  age  of 
forty  which  begins  to  enlarge  or  to  produce  by  tension  pain  which  radiates 
over  the  neck  or  to  the  jaw  may,  in  the  absence  of  inflammatorv  condi- 
tions, be  regarded  as  malignant.  Inflammatory  conditions  may  cause 
similar  conditions.  Dysphagia  from  an  enlarged  thyroid  is,  according 
to  Liicke,  due  either  to  a  malignant  growth  or  to  thyroiditis.  With  the 
further  extension  of  the  disease  the  glands  become  involved,  the  various 
nerve  phenomena  appear,  the  skin  may  become  involved,  and  ulcera- 
tion  occur. 

Prognosis. — Carcinoma  of  the  thyroid  is  one  of  the  most  malignant 
forms  of  the  disease.  Very  few  cases  have  been  cured  b\-  operation 
(Ewald  could  quote  but  foun,  but  in  recent  ^ears  operative  cures  seem 
to  be  more  frequent.  When  they  are  left  untreated,  death  occurs  in 
some  cases  by  cachexia  and  exhaustion,  but  is  more  frequentiv  due  to 
involvement  of  the  respiratory  tract;  edema  of  the  glottis,  compres- 
sion or  invasion  of  the  trachea,  secondary  pneumonia  or  hemorrhage 
from  the  erosion  of  a  vessel  are  also  causes  of  death. 

Treatment. — Operative  removal  ma\-  be  undertaken  when  the  diag- 
nosis IS  made  early.  The  operation  at  best  is  a  formidable  one,  and  is 
quite  useless  when  invasion  of  the  surrounding  tissue  has  taken  place. 
\\  hen   there  is  obstruction  to  respiration,  tracheotomy  may  relieve  the 

^  Eiselsberg,  Arcfi.  f  klin.  Chir.,  1893,  .\lvi,  430. 
-  Hinterstoi.sser,  Billroth's  Festschrift,  1892. 
25 


386 


TUMORS  OF  THE  NECK 


condition.  Esophagotomy  may  be  employed  when  the  esophagus  is 
compressed,  though  rectal  feeding  is  recommended  b}'^  Ewald  instead  of 
this  operation.  Gastrostomy  would  seem  a  better  palliative  operation 
where  the  esophagus  is  occluded  than  any  attempt  to  find  the  esophagus 
so  near  the  malignant  growth. 

Sarcoma. — These  tumors  are  uncommon,  occurring  about  one-fourth 
as  frequently  as  carcinoma  (Ewald).  Liicke^  states  that  they  occur  most 
frequentl)^  in  the  j^oung,  but  this  is  disputed  by  Tiffany  and  Lanier.- 
They  are  usuall}/^  of  rapid  growth  and  invade  early  the  capsule  (Fig.  285) 
and  the  surrounding  tissue.  They  produce  much  the  same  disturbances 
in  this  invasion  as  were   detailed  in  the  discussion  of  carcinoma.      Sar- 

FiG.  285 


Sarcoma  of  the  thyroid  gland. 

comas  go  out  from  the  interstitial  tissue  of  the  gland,  and  all  cell  types 
have  been  described.  The  surface  is  usually  smooth,  sometimes  slightly 
nodulated;  on  section,  the}'  are  smooth,  white  or  pink,  and  ghstening. 
The  treatment  is  operative  removal  if  the  diagnosis  can  be  made  early 
enough.  Otherwise,  the  methods  of  palliation  described  under  carcinoma 
may  be  employed. 

Rare  Tumors. — Fibromas  and  lipomas  have  been  described. 


1  Krankheiten  d.  Schildruse,  Enke,  Stuttgart,  1875. 

2  Ann.  of  Surg.,  1897,  xxvi,  498. 


C.I  Ron  I)  ri  MORS  387 


TUMORS    OF    THE    PARATHYROID 

Bur   rlirce  cases  ot   rumors  ot    rliis   i;l;iiul    h:i\c-   hcen   rc-porrt-cL       I  lu- 
diajiiiosis  IS  iiiaclt-  ui  the  hihoi  atory.' 


CAROTID    TUMORS 

riu-  (.xisrcnci-  of  a  sj^ccuil  r\  pi-  ot  rumor  springing  from  the  carc^tul 
ghiiul  has  now  been  estahhsheti.  I  he  Hrst  observation  was  published 
b\'  Marchand,  and  was  followed  the  next  \ear  by  a  description  (jt  four 
cases  b\'  Paltauf.-  Ihe  general  character  of  these  tumors  is  constant, 
but  there  aie  numerous  secondary  characteristics  that  van'  in  the  differ- 
ent cases  reported.  They  have  occurred  about  equalh'  between  the 
sexes  and  in  age  between  the  eighteenth  and  sixtieth  ^ears.  About 
three-fourths  of  the  cases  have  occurred  on  the  left  side;  which  fact 
has  given  rise  to  various  suppositions  as  to  etiology,  for  instance,  that 
the  more  direct  force  of  the  blood  stream  on  this  side  may  have  a  causal 
relation. 

The  nature  of  these  tumors  is  still  uncertain.  Because  of  the  number 
and  size  of  the  vessels  and  the  nearness  of  the  tumor  cells  to  the  vessel 
walls  Marchand  classed  them  as  angiosarcomas.  He  believed  that  the\' 
spring  from  the  connective  tissue  surrounding  the  capillary  loops. 
Later  writers  have  followed  the  general  disposition  of  Borst  and  Ribbert 
to  abandon  the  designation  angiosarcoma,  and  have  classed  them  with 
the  endotheliomas  or  peritheliomas.  Clinically  these  tumors,  because 
of  their  slight  disposition  to  form  metastases,  correspond  very  well 
\vith  the  endothehomas.  Histologicalh'  this  seems  satisfactory,  but, 
as  pointed  out  by  Monckeberg,  if  the  cells  of  these  tumors  are  derived 
from  the  cells  of  the  carotid  glands,  an  alignment  with  the  endotheliomas 
would  cause  confusion. 

Pathology. — The  tumors  reported  have  varied  in  size  from  a  pigeon's 
egg  to  a  good-sized  apple,  and  are  irregularh"  oblong  (hence  the  name 
potato  tumor).  They  are  firm  in  consistency,  except  in  a  few  cases 
in  w^hich  the}'  are  described  as  soft  and  elastic.  On  section  they  have 
been  described  as  usually  reddish  brown,  and  occasionally  grayish  yellow. 
Tneir  brow^n  color  is  due  to  the  collection  of  pigment  in  the  connec- 
ti\e-tissue  spaces.  From  the  relationship  of  this  pigment  to  extrava- 
sated   blood  it  has    been    inferred    that    it  is  of    hemic  origin.      As  to 

'  \V.  G.  MacCallum,  Johns  Hopkins  Hosp.  I^ull.,  1905,  xvi,  87. 
-  Beitr.  z.  path.  Anat.,  1892,  ii,  260. 


388 


TUMORS  OF  THE  NECK 


structure  macroscopically,  they  are  homogeneous  or  show  bands  of 
fibers  intermingled  with  granular  or  spongy  areas,  and  in  some  of  them 
numerous  bloodvessels  and  spaces  are  seen  on  cross-section.  Micro- 
scopically, they  are  made  up  of  an  alveolar  arrangement  of  cells  with 
a  small  amount  of  connective  tissue,  the  cells  being  in  close  association 
with  the  bloodvessels.  The  cells  are  large,  with  from  one  to  six  large 
nuclei,  each  bearmg  one  or  two  nucleoli.  The  chromatin  of  the  nucleus 
is  grouped  about  the  periphery.  The  protoplasm  of  the  cells  is  rather 
abundant  and  is  sometimes  vacuolated,  the  vacuoles  depending,  accord- 
ing to  Monckeberg,^  upon  the  hardening  fluid  emplo)"ed.     He  adopts 

Fig.  286 


Carotid  tumor:     a,  internal  carotid  artery;  b,  external  carotid  artery. 

this  view  because  certain  cells  in  carotid  tumors  stain  yellow  in  tissue 
hardened  in  Miiller's  fluid,  resembling  in  this  respect  cells  occurring 
m  the  normal  gland  and  in  hypernephroma.  He  also  observed  that 
the  cells  of  these  tumors  react  to  the  various  hardening  fluids  like  those 
of  the  normal  gland.  In  none  of  these  specimens  has  an  intercellular 
connective  tissue  been  found.  There  has  been  a  deviation  from  this 
common  type  in  some  of  the  specimens  which  showed  solid  columns  of 
cells,  and  m  others  in  which  the  connective  tissue  predominated;  some 
of  the  specimens  presented  two  or  more  of  these  types  of  arrangement. 


^  Die  Tumoren  der  Glandula  Carotica,  Fischer,  Jena,  1905. 


CIRnrih    77  MORS 


389 


Symptoms.  (.  .noiul  iuiikhs  oihui  ;is  ili  use  il.istu'  potato-sliapiil 
tumors  III  tin  hit  iiK.it  loii  (»t  tin  i.iioikI  Iil:,.  2.S()j;  that  is,  at  the  lc\el 
ol  tlu-  h\(»ul  hoiu-.  Mu\  iisii.ilU  .ipiu;ii  in  front  of  tht-  stfrnoniastoul 
miisiK  '  I' in.  2S7),  luit  as  th(\  hcroiiu  hii'^ii  th(\  tend  to  j^row  under 
It.  Mu  (Atriision  IS  iipw.iid  i.ilh(i  ih.m  ch  i\\  iiw  a  1  d .  Mn  skin  co\'cr- 
injj,  thiiii  nio\i's  tuih  and  the  iiiniois  ha\i-  a  limned  hiteral  hut  no 
vertical  motMht\  ;  thi\    ch)  not    mo\c  o\ei    tht-  underlymfi;  tissue.      1  he}' 

Fig.  2«7 


Carond  tumor. 


transmit  the  pulsation  ot  the  carotid,  and  m  some  of  the  cases  reported 
the  tumors  moved  upward  shghtly  with  each  pulsation  of  the  arter\'. 
They  are  usualh'  dense,  but  may  be  so  soft  as  to  be  mistaken  for  lipoma, 
as  in  Keen's  case;  they  usually  grow  slowh',  resembling  in  this  the  mixed 
tumors  of  the  parotid;  at  time  of  operation  the  duration  of  the  tumors 
reported  had  varied  between  eighteen  months  and  thirt\'-six  \-ears. 
1  hey  are  usuall}'  painless,  but  sometimes  cause  slight  pain  and  slight 
limitation  of  the  rotation  of  the  head.  The}'  are  alwa^•s  isolated  and 
have  a  more  or  less  distinct  capsule.    Metastasis  was  reported  in  regional 

'  Keen,  Jour.  Aiiier.  Med.  Assoc,   1006,  \lvii.  469  and  566. 


390  TUMORS  OF  THE  NECK 

lymph  glands  in  one  instance  (Monckeberg).  Their  malignancy  is 
shown  by  their  tendency  to  invade  the  surrounding  tissue  even  through 
the  vessel  wall. 

Diagnosis. — Their  location,  ovoid  shape,  slow  growth,  relation  to 
vessels,  general  consistency,  and  isolated  occurrence  are  enough  to 
make  a  presumptive  diagnosis.  Most  of  the  cases  reported  were  not 
diagnosticated  before  operation.  In  Keen's  case  the  close  relation 
of  the  tumor  with  the  vessels  and  the  brownish  color  caused  the 
operator  at  first  to  think  of  an  aberrant  thyroid,  and  only  the  associa- 
tion with  the  bloodvessels  led  to  the  correct  diagnosis.  Their  rate  of 
growth  and  isolated  occurrence  distinguish  them  from  the  lymphomas. 
In  addition  they  seldom  involve  the  Ij^mph  glands,  but  even  if  thej^ 
do,  their  relation  to  the  vessels  is  quite  distinctive.  Tumors  of  the 
branchial  clefts  may  simulate  carotid  tumors,  but  they  usually  extend 
nearer  the  buccal  mucous  membrane  and  can  be  pushed  so  as  to  appear 
to  project  into  the  floor  of  the  mouth;  however.  Keen's  case  of  carotid 
tumor  also  projected  into  the  floor  of  the  mouth.  They  are  more  globular 
and  less  movable  than  lipomas. 

Treatment. — Excision  should  be  practised  only  in  the  presence  of  special 
indications.  The  deformity  is  usually  what  causes  the  patient  to  seek 
relief,  less  often  the  slight  pain.  If  the  tumor  has  grown  slowly,  a  con- 
servative course  is  to  be  recommended.  Resection  of  the  carotid,  the 
veins,  and  the  vagus,  a  procedure  required  in  all  but  a  few  cases^  makes 
the  operation  a  formidable  one,  and  it  should  not  be  undertaken  with- 
out the  patient  having  full  knowledge  of  the  risk  incurred.  Reclus 
and  Chevassu^  recommend  operation  only  when  serious  functional 
trouble  or  evidence  of  malignancy  is  present.  Keen  concurs  heartily 
with  these  conclusions.  The  operation,  all  are  agreed,  is  facilitated 
by  ligation  of  the  common  carotid  below  the  tumor  and  detaching  the 
tumor  from  below  upward,  taking  care  to  avoid  the  pneumogastric. 
The  superior  thyroid  and  facial  arteries  require  ligation.  The  tumor 
mass  together  with  the  vessels  are  then  lifted  up  and  the  vessels  again 
tied  when  the  tumor  has  been  freed.  The  mortality  from  the  opera- 
tion has  been  27  per  cent.,  supposedly  due  to  section  of  the  vagus  and 
hemorrhage.  When  the  tumor  has  been  recognized  early  before  the 
vessels  and  nerves  are  extensively  involved,  immediate  operation 
may  be  advised.  At  this  time  the  operative  risk  is  small  and  the  more 
formidable  operation  will  be  avoided.- 

^  Rev.  de  chir.,  1903,  xxviii,  149,  388. 

^  Douglas,  Med.  Rec,  New  York,  1909,  Ixxv,  397. 


CM  \ r  r  K  R    x  \  I  x 

IL.MORS  OV    lllh  CUKSr,  MKDIAS  1  IM  M,  llhARl,  AND 

LUNGS 

TUMORS    OF    THE    CHEST 

Superficial  Tumors  of  the  Chest.  I  lu-  skin  ot  rlu-  chest  is  siihjccr, 
with  slight  niodiHcations,  to  the  same  tumors  as  the  skm  elsewhere. 

Carcinoma.  In  the  clavicular  region  and  about  the  shoulders  carcino- 
mas are  observed  with  relative  frequency.  1  hey  are  slow  growmg  and 
tend  to  spread  o\er  a  considerable  area.  Growths  the  size  of  a  palm 
are  not  rare,  and  much  larger  ones  are  sometimes  observed.  1  hey  form 
ulcers  with  but  slightl\'  elevated  borders.  fhere  is  some  increase  m 
densit}',  but  it  is  not  so  marked  as  in  carcinoma  in  many  other  regions. 
They  must  be  excised  and  the  defect  resulting  must  be  covered  with 
grafts.     Local  recurrences  are  common. 

Tuberculous  Ulcer. — The  tuberculous  ulcers  are  seen  more  often  on 
the  back  than  on  the  chest.  The\"  are  superficial  spreading  ulcers 
which  closel)'  resemble  carcinoma,  but  proceed  more  slowly.  They  show 
a  tendenc}'  to  heal  in  the  centre  while  advancmg  about  the  border. 
The  edge  is  not  infiltrated.  Tuberculous  lesions  of  the  skin  may  be 
secondary  to  disease  of  the  subjacent  bones,  especiall}'  ot  the  ribs  and 
sternum,   but  also  ot   the  spine. 

Curettage,  the  cautery,  and  Finsen  ra\s  have  been  used  with  success. 
The  .v-ra^s  ma)'  be  tried.  When  the  extent  of  the  disease  permits, 
excision  and  grafting  is  the  method  which  gives  the  most  rapid  results. 

Syphilis. — About  the  scapula  and  clavicle  are  the  regions  of  predilec- 
tion for  gummas  and  syphilitic  ulcers.  The\'  give  the  histor\'  ot  acute 
onset,  and  the}'  have  the  peculiar  kidney  shape  and  the  soft  overhang- 
ing edges  characteristic  of  syphilis.  Signs  of  the  disease  elsewhere 
and  the  use  of  potassium  iodide  soon  clear  up  the  diagnosis. 

Keloids. — The  anterior  surface  of  the  chest  is  one  of  the  commonest 
seats  of  keloid.  They  are  smooth,  elevated,  dense  tumors,  confined 
to  the  skin  and  subcutaneous  tissue,  are  of  slow  growth,  and  remain 
often  for  years  without  notable  change.  They  ma\'  occur  singly  or  in 
large  numbers.  The  chief  location  is  about  the  sternum  and  between 
the  shoulder-blades,  though  when  multiple  they  may  be  scattered  over 
the  entire  trunk. 


392      TUMORS  OF   THE  CHEST,  MEDIASTINUM,  HEART,  AND  LUNGS 

Deep  Tumors  of  the  Chest. — Sarcoma. — These  tumors  occur  with 
relative  frequenc}"  on  the  anterior  surface  of  the  chest.  In  the  majorit}^ 
of  instances  the}^  go  out  from  bone  or  cartilage,  and  appear,  therefore, 
as  osteo-  or  chondrosarcomas.  They  are  frequentl}^  preceded  by  trauma- 
tism. Their  more  or  less  dense  bosselated  surface,  their  immobility 
upon  the  deeper  structures,  and  the  relatively  rapid  growth  are  sufficient 
to  characterize  them. 

Lipoma. — Lipomas  are  relatively  infrequent  about  the  chest,  but 
when  they  occur  are  found  particularly  near  the  clavicle  and  along 
the  costochondral  junction.  They  are  identical  m  diagnosis  and  treat- 
ment with  lipomas  found  elsewhere. 

Diagnosis. — Tuberculosis  and  actinomycosis  may  involve  any  of 
the  bones  in  this  region  and  bring  up  the  question  of  possible  sarcoma. 
They  are  of  slow  growth.  Actinomycosis  may  be  detected  by  the 
discovery  of  the  canary  yellow  bodies  and  the  demonstration  of  the  ray 
fungus.  Tuberculosis  may  be  detected  by  the  peculiar  granulation 
tissue  and  by  the  type  of  bone  involvement. 

Metastatic  tumors  from  other  regions  not  infrequently  find  lodge- 
ment in  the  ribs  and  sternum.  Syncytiomas  and  hypernephromas  may 
be  discovered  in  this  region  before  the  primary  tumor  is  suspected. 
Carcinomas  of  the  breast,  too,  though  rarel}^,  show  early  metastasis 
in  these  bones  where  they  may  present  spindle-form  enlargements  which 
closely  resemble  sarcomas.  When  the  primary  tumor  is  hidden,  as 
in  small  hypernephromas,  a  diagnosis  can  be  made  only  by  microscopic 
examination,  and  even  then  may  be  difficult. 

Aneurysms  which  appear  in  this  region  are  most  commonly  con- 
nected with  the  arch  of  the  aorta  and  exist  commonly  as  distinct  tumors 
after  they  have  eroded  the  ribs  or  sternum.  They  present  a  smooth 
surface  over  which  the  skin  is  freely  movable,  and  are  fluctuating  or 
semifluctuating.  Their  location  and  the  transmitted  impulse  of  the 
heart  are  ordinarily  sufficient  for  a  diagnosis.  Sometimes,  however, 
when  they  are  filled  with  coagulum  this  may  not  be  noticed.  It  should 
be  made  a  rule  in  observing  all  tumors  in  this  region  to  exclude  aneurysms 
by  careful  physical  examination  of  the  heart  before  instituting  treat- 
ment. Very  disastrous  consequences  have  followed  the  disregard  of 
this  rule. 

Treatment. — Extensive  operations  are  required  for  the  removal  of 
sarcomas,  and  the  prognosis  with  or  without  treatment  is  almost  equall}" 
bad.  Extensive  resections,  even  to  include  a  portion  of  a  lung,  have  been 
done  with  at  least  temporary  success.  With  the  use  of  the  newer  methods 
of  chest  surgery  more  favorable  results  may  be  expected  in  the  future. 
When  metastatic  tumors  occur  in  this  region  little  or  nothing  can  be 
expected  from  any  form  of  treatment,  though  if  the  tumor  is  the  only 


77  MORS   (II    1111      \!  I  DI.ISriM  M  393 

nu't  ast  asis      liimi      .i     li  \  [k  i  in  pli  i  (  mim,     icmox.il    nt     Imili  |)riinai\'     aiul 

sec()iuiai\    Illinois   ini^lit    ti,i\i-  soiiu-   piospcii    of   smccss.  l.i|ioiiias  ;iie 
casih     slicllcti    out. 


TUMORS    OF    THE    MEDIASTINUM 

General  Conception.  I'nmaiv  and  ,s((.()iulai\  luinois  ol  the  incdias- 
iiiniin  all'  amonu  llic  laiir  ntoplasms,  hiii  ihc  h((|ii(iu\  wiili  winch 
iluii  possible.'  cxistciicc  imisr  he  rciiuiiilHiccl  m  rlu-  consulciation  of 
otiu'i  (.liscasfs,  notably  discast-s  of  the  heart  and  hloocUessels,  ^i\e  theni 
a  uieater  di<2;nity  than  tlu\    would  coniniami  ot  their  own  aecount. 

Types  of  Tumor.  Sarcoma.  Primary  sarcoma  of  the  mediastinum 
may  he  composed  ot  any  of  the  cell  types,  the  small-celled  variet\' 
predominatinti;.  The  point  of  origin  ma\'  be  connective  tissue  or,  more 
commonly,  the  lymphatic  <i;lands.  Rapid  growth  is  their  chief  char- 
acteristic. Secondar\'  sarcoma  is  less  common,  and  when  present  is 
usually   by   direct  extension. 

Carcinoma.  When  primary  the  j")()int  of  origin  is  usuall\  within  the 
pulmonary  epithelium,  usually  that  of  the  bronchi;  they  may  be  small 
and  not  clmically  manifest.  Carcinomas  of  the  mediastinum  are,  how- 
ever, usually  secondary,  being  extensions  from  the  lungs  or  from  the 
regions  below  the  diaphragm  or  about  the  head  and  neck. 

Lymphomas. — Lymphatic  enlargement  may  be  sufficient  to  give 
evidence  of  a  mediastinal  tumor.  Tuberculosis,  Hodgkin's  disease, 
or  s\philis  may  cause  such  enlargement. 

Rarer  Forms. — Dermoids  of  the  mediastinum  are  sometimes  observed.' 
The}'  are  usuall}'  situated  in  the  upper  part  of  the  mediastinum.  Enchon- 
dromas  are  sometimes  encountered.  Hoffmann-  reports  se\en  cases  of 
fibrous  substernal  thyroids  which  ma\'  give  the  s\'mptoms  of  tumors. 

Symptoms. — The  s\'mptomatolog}'  of  mediastinal  tumors  depends 
upon  their  situation,  size,  and  rate  of  growth.  The  malignant  tumors 
are  usually  quick!)'  fatal,  and  it  is  this  rapid  progression  of  mediastinal 
disease  that  makes  the  diagnosis  easy.  The  age  of  the  patient  gives 
some  evidence,  the  sarcomas  being  more  frequent  in  the  young.  The 
specific  symptoms  are  compression,  disturbance  of  the  voice,  and  dis- 
placement of  the  heart.  The  paral\'sis  of  the  vocal  cords  may  be 
detected  sometimes  earl\-  m  the  course  of  the  disease,  but  it  gi\"es  no 
evidence  as  to  the  character  of  the  tumor.  Bradycardia  and  disturb- 
ance in  deglutition  or   respiration    from  pressure  on  the  vagus  may  be 

^  Pflanz,  Zrschr.  f.  Heilk.,  1896,  xvii,  473. 

-Spec.  Path.  u.   Therap.;  Xotlinagel,  Holder,  W'ien,  1896,  .\iii,  192. 


394     TUMORS  OF  THE  CHEST,  MEDIASTINUM,  HEART,  AND  LUNGS 

present.  When  the  return  flow  of  the  blood  is  interfered  with,  dilata- 
tion of  the  superficial  veins  of  the  chest  and  abdomen  is  often  marked. 
When  the  tumor  invades  the  sternum,  or  becomes  adherent  to  the  pleura 
in  the  region  of  the  intercostal  spaces,  dilatation  of  the  veins  over  the 
seat  of  the  tumor  is  often  pronounced.  The  x-rays  may  give  evidence 
of  a  tumor,  but  give  little  evidence  of  its  character.  In  children,  the 
growth  of  the  tumor  may  produce  some  deformity  of  the  sternum  or 
ribs.  Physical  examination  may  show  substernal  dulness,  and  if  a 
bronchus  is  compressed  dimmished  respiratory  murmurs.  Edema  of 
the  extremities  may  occur  if  there  is  pressure  on  the  veins.  Medias- 
tinal tumors  of  slow  growth  are  probably  dermoids,  if  lymphoma  and 
tuberculosis  can  be  excluded.  In  a  few  instances  the  presence  of  hair 
in  the  matter  expectorated  has  cleared  the  diagnosis. 

Diagnosis. — Aneurysm  is  most  frequently  the  disease  confused 
with  mediastinal  tumors,  which  is  in  itself  essentially  a  blood  cyst 
or  hematoma.  Aneurysm  is  distinguished  by  the  bruit  and  the  asso- 
ciated sj^mptoms  on  the  part  of  the  circulation.  Adhesive  pericarditis 
may  give  the  obstructive  symptoms  of  tumor  without  the  symptoms 
of  pressure. 

A  tumor  cannot  be  identified  with  certainty  unless  it  is  secondary 
and  the  primary  tumor  is  accessible  and  capable  of  diagnosis.  Rapidity 
of  growth,  particularl}^  in  young  persons,  is  strongly  presumptive  of 
sarcoma.  Tuberculosis  of  lymphatics  can  usually  be  recognized  by 
the  presence  of  similar  diseases  elsewhere,  or,  if  this  is  not  present,  the 
course  of  the  disease  may  give  presumptive  evidence. 

Treatment. — Roser  drained  a  dermoid  through  and  above  the  clavicle. 
Six  cases  in  all  have  been  operated.  It  is  but  rarely  that  benign  tumors 
are  subject  to  surgical  intervention  and  malignant  tumors  are  not 
subject  to  any  form  of  treatment. 


TUMORS    OF   THE   HEART 

Tumors  of  the  heart  are  extremely  rare  as  primary  tumors.  Fibromas 
and  lipomas  (Fig.  288)  have  been  observed.  Secondary  tumors  are 
not  uncommon.  The  melanotic  sarcomas  involve  this  organ  most 
often,  though  other  varieties  of  sarcoma  and  carcinomas  as  well  form 
metastases  here. 

Clinically,  they  give  no  specific  symptoms,  and  their  discovery  is 
a  matter  of  postmortem  findings.  They  are  most  apt  to  be  mistaken 
for  gummas,  and  a  microscopic  examination  is  often  needed  to  make 
the  difi^erentiation. 


rr.MoRs  or  riii:  i.i  scs 

Fig.  ;-88 


:ju5 


Liponni  of  the  heart.     (From  specimen  loaned  b\-  J.  C.  Stewart.) 


TUMORS    OF    THE    LUNGS 

General  Conception. — Tumors  of  the  lungs  are  a  ver}-  frequent  end 
result  of  carcinomas  and  particular!}'  sarcomas  situated  elsewhere. 
Evidence  of  pulmonary  involvement  during  the  course  of  malignant 
disease  is  presumptive  evidence  that  metastases  have  formed  in  the 
lungs.    On  the  other  hand,  primary  tumors  of  the  lungs  are  rare. 

Primary  Tumors  of  the  Lungs.  Benign. — The  primar)-  non-malig- 
nant tumors  of  the  lungs  have  been  almost  without  exception  autopsy- 
findings.  \'ery  small  suhpleural  or  intrabronchial  lipomas  have  been 
described.  Fibromas,  though  more  frequent  than  lipomas,  are  rarities. 
Chondromas  or  mixed  tumors  containing  cartilage  and  also  dermoids 
have  been  noted  a  number  of  times.  Some  of  them  have  been  large 
enough  to  give  clinical  symptoms,  and  in  case  of  the  dermoids  expec- 
toration of  hair  has  sometimes  made  a  clinical  diagnosis  possible. 
Hertz  regards  it  as  probable  that  the  primary  seat  of  these  dermoids 
is  in  the  mediastinum. 

Malignant. — Carcinom.a. — Primary  lung  carcinomas  comprise  probable- 
less  than  I  per  cent,  of  all  carcinomas.  They  go  out  from  the  alveolar 
or  bronchial  epithelium  or  from  the  bronchial  glands.  The\-  are  most 
frequent  about  the  hilum.     In  lo  per  cent,  of  the  cases  reported  they  are 


396     TUMORS  OF  THE  CHEST,  MEDIASTINUM,  HEART,  AND  LUNGS 

said  to  have  been  bilateral,  though  whether  primarih'  so  or  by  exten- 
sion is  in  most  cases  not  clear.  The}^  tend  to  extend  about  the  bronchi, 
frequenth^  compressing  them,  and  in  rarer  instances  have  grown  mto 
the  lumen  of  the  bronchi.  The  lung  substance  is  rarely  invaded.  In 
size  they  have  varied  from  a  hazelnut  to  an  orange,  though  in  isolated 
instances  the  larger  part  of  a  lobe  has  been  involved.  As  to  structure, 
all  varieties  have  been  observed.  In  the  few  cases  in  which  metastases 
occurred  these  were  found  in  the  liver  or  in  the  bronchial  glands.  Owing 
to  the  obscure  clinical  manifestation  of  carcinoma  of  the  lungs  their 
rate  of  development  in  most  instances  could  not  be  determined,  though 
It  is  known  that  those  of  the  infiltrating  type  tend  to  run  a  rapid  course. 

Sarcoma. — Owing  to  the  imperfect  distinction  between  the  various 
types  of  malignant  disease  the  relative  frequency  of  primary  lung 
sarcoma  cannot  be  estimated,  though  some  authors  venture  to  suggest 
a  proportion  to  carcinoma  of  i   to  4. 

All  the  cellular  types  of  sarcoma  have  been  observed  as  well  as  those 
with  myxomatous  and  cystic  degeneration.  They  are  situated  usually 
about  the  hilum  and  the  differentiation  between  lung  and  mediastinal 
sarcoma  is  often  difficult.  They  are  said  to  occur  with  special  fre- 
quency in  cobalt  and  arsenic  workers. 

Endothelioma. — In  recent  years  a  number  of  tumors  of  this  char- 
acter have  been  reported.  They  develop  usually  from  the  subplural 
lymph  spaces,  though  they  may  develop  from  the  surface  of  the  entire 
lung.  They  tend  to  extend  over  the  surface  of  the  entire  lung,  forming 
a  flat  tumor  from  which  numerous  bands  extend  into  the  interior.  In 
accord  with  the  usual  course  of  these  tumors  they  are  of  slow  develop- 
ment, and  do  not  tend  to  form  metastases. 

Symptoms. — Dulness  on  percussion,  loss  of  respiratory  murmur,  and 
limitation  of  the  respiratory  excursions  of  the  chest  wall  are  observed 
when  the  tumors  are  large.  The  presence  of  dilated  subcutaneous 
veins  when  confined  to  one  side  of  the  chest  is  the  most  reliable  sign, 
and  in  the  presence  of  the  signs  previously  mentioned  is  presumptive 
evidence  of  tumor. 

Diagnosis. — Chronic  empyema,  lung  abscess,  and  actinomycosis  may 
resemble  lung  tumors,  and  can  be  excluded  by  considering  the  signs  of 
those  diseases.  Sarcomas  of  the  lungs  are  often  accompanied  by  rise 
of  temperature  and  leukocytosis. 

Treatment. — There  is  no  treatment,  and  attempts  at  operative  inter- 
ference undertaken  under  a  mistaken  diagnosis  are  detrimental  to  the 
patient. 

Secondary  Tumors  of  the  Lungs. — When  the  existence  of  a  tumor 
known  to  be  capable  of  producing  lung  metastasis  is  recognized,  the 
nature  of  a  lung  complication  should  be  easily  determined.     Notwith- 


riMfJks  or  Tin:  i.isc.s  :\\)1 

sniiuliiiL:,  SIR  li  (>l)\i«)iis  I  thi  t  ii)iislii|),  p;iii(nt.s  ;n  r  f  iit|iitiit  l\  opiiaticl 
upon  toi  (>\;iii;in,  list  uiihii ,  and  m;iiiim;ii\  tiiniois  wlu-n  pulmonary 
coiniilicatioiis  ixisr.  I  In-  ic-sult  is  hut  to  hastiii  rlic-  fatal  t-nd.  1  lu- 
lunj;  s\  iiiptoms  ina\  hv  loiiHiud  to  a  sli<;ht  coii^h  and  iiUTcascd  it-spiia- 
r()i\'  latc.  In  nion  cxtcnsiNC  nnoKt-nuiii,  d\  spina  and  loiali/ici 
areas  ot  duliuss  nia\  l)i-  disioxc  ricl.  1  lu-  most  dcHmtc  symptom  ot 
primai\  lun<;  niali^nanc\  ,  rlif  dilaicd  superficial  \'essels,  dois  not 
appear  ui  sicoiulai  \  tumors.  I  he  situation  is  more  difficult  wlu-n  the 
existeiUH-  of  a  |-»rimai\  tumor  is  not  rt-co^m/A-d.  ()\arian  sarcomas 
ma\'  produce  lunji  metastases  hefore  the  existence  (^f  the  pelvic  tunu>r 
is  reco<z;ni/ed.  1  esticular  and  th\r()id  tumors,  occasionally  tumors 
of"  the  nu)uth  aiul  intestinal  tract,  present  their  first  s\-mptoms  in  the 
lungs. 

Of  equal  interest  are  lung  metastases  after  the  removal  of  the  primar\- 
tunu)r  without  local  recurrence.  Sarcomas  of  the  extremities  for  which 
amputation  has  been  done,  testicular  tunu)rs  in  which  castration  and 
removal  of  the  cord  has  been  practised,  ovarian  tumors  which  have  been 
removed,  without  local  recurrence,  may  be  followed  often  after  many 
years  b}'  secondary  tumors  of  the  lungs.  If  the  patient  has  had  a  malig- 
nant growth  removed,  the  advent  of  an  obscure  pulmonar\'  involve- 
nu^nt  should  excite  suspicion  and  any  other  disease  should  be  diagnosti- 
cated only  on  the  discovery  of  positive  evidence,  as,  for  instance,  the 
demonstration  of  pus,  tubercle  bacilli,  etc.  The  existence  of  tempera- 
ture and  leukocytosis  in  tumors  often  leads  to  error.  Dulness  or  localized 
diminished  vocal  resonance  in  the  middle  of  the  lung  warrants  a  probable 
diagnosis  of  metastatic  tumor  if  the  patient  has  had  a  malignant  growth, 
particulaih    if  the  primary  tumor  was  a  sarcoma. 


CHAPTER    XXX 
TUMORS  OF  THE  MAMMARY  GLAND 

General  Conception. — There  is  no  region  of  the  body  richer  in  objects 
for  tumor  stud}'  than  the  female  breast,  and  none  in  which  an  accurate 
knowledge  of  diagnosis  and  treatment  finds  more  frequent  chances  for 
exercise.  These  facts  are  due  to  the  exposed  position  of  the  gland  and 
to  its  proneness  to  tumor  formation,  and  also  to  the  various  changes 
to  which  it  is  normally  subject  in  performing  its  functions  and  to  the 
numerous  perversions  these  functions  may  undergo.  A  survey  of  these 
possibilities  may  form  a  suitable  introduction  to  a  more  detailed  study 
of  the  various  tumors  and  the  conditions  which  simulate  them. 

The  breasts,  like  the  sebaceous  and  sudoriferous  glands,  develop 
from  an  ingrowth  of  the  epiblast.  The  glands  are  at  first  simple,  but 
with  the  approach  of  puberty  become  complex  by  a  process  of  budding 
off  from  the  primary  acini.  This  process  may  go  on  to  excess  and  pro- 
duce the  rare  condition  of  mammary  hypertrophy.  Much  more  frequent 
is  the  local  hyperplasia  of  both  glandular  and  fibrous  tissue,  producing 
the  fibro-adenoma.  With  the  advent  of  lactation  the  complexity  of  the 
structure  increases  and  the  cells  enlarge  and  undergo  characteristic 
changes.  Lactation  is  frequently  complicated  b}^  acute  or  chronic 
inflammatory  processes  which  may  produce  more  or  less  permanent 
changes.  They  may  result  in  a  general  increase  of  fibrous  tissue  which 
may  remain  unchanged  as  a  simple  mastitis,  or  may  give  rise  to  further 
pathological  alterations.  Among  these  may  be  the  occlusion  of  a  duct 
and  the  production  of  a  cyst;  chronic  irritation  of  a  nature  little 
understood  which  leads  to  epithelial  proliferation  and  produces  a  senile 
parenchymatous  hypertrophy;  further  changes  in  the  epithelium  and 
connective  tissue  may  ensue  either  as  an  end  result  of  one  of  the  foregomg 
or  as  a  primary  process,  leading  to  the  invasion  of  the  surrounding 
tissue  and  the  formation  of  metastases. 

This  brief  outline  indicates  how  closel}^  the  tumors  of  the  breast 
are  associated  with  its  functions  and  diseases.  These  conditions  so 
correlated  account  for  the  great  majority  of  the  tumors  of  the  breast. 

Adenofibroma  and  Fibro-adenoma.^ — These  tumors  are  composed  of 
glandular  and  fibrous  tissues.     The  latter  usually  predominates,  some- 

^  For  a  review  of  the  recent  literature  on  benign  tumors  of  the  breast  see  v.  Saar, 
Ergebnisse  der  Chirurgie,  Bd.  1,  p.  413,  Springer,  BerHn,  1910. 


.im\()l  IHRO.MI   .l\l)   I  IHRo  .ll)l.\t)\l.l 


399 


tinus  (.•.\ctssi\cl\'  ( luiuc  die  ikiiiu  adi  iiotihioiiKi ) ;  \  i-r  tlusc  tiiiiiois 
:iii-  pi()ptil\  tl;iss(,d  with  ilu-  ipiili(li;il  mnii|).  When  the  ^hiiuliihir 
tliiiuiit   pi(  (loniiiKitt  s  tlu\    ;iic-  more  pr()|)iil\    t;illi(l    Hhro-iicltiiomas. 


I-ibro-adenoma  with  its  capsule  remoxed  and  spread  out,  sho\vin<i  the  sH«ilit  attachment 

between  tumor  and  capsule. 

Fig.  290 


•  '■  v.      •  ?    y  ••'    '     '  '  •'••  >   •  '.V' 
.  K .?..    V.,-.. .  .^.        ...  /ci^'-- 


•  *•••.  iN    •(•        .,•' 


Fibro-adenoma  of  the  breast,  showinji  small  uland  uroups  m  the  mass  of  connective 

tissue. 


1  lie    hbromatous    group    occurs    most    fret]ueiitly    m    young    women 
soon  after  puberty.     The  glandular  type  occurs  somewhat  latei',  usually 


400  TUMORS  OF  THE  MAMMARY  GLAND 

between  the  twenty-fifth  and  thirty-fifth  years.  Tumors  of  this  type 
form  globular  masses  varying  from  the  size  of  a  hazelnut  to  that  of  a 
walnut.  They  are  dense  and  smooth  to  the  touch,  but  occasionally 
are  sHghtly  nodular.  They  are  fully  encapsulated  (Fig.  289),  and 
glide  about  under  the  examining  fingers.  The  upper  quadrant  of  the 
breast  is  the  usual  location.  Patients  sometimes  complain  of  a  slight 
burning  pain.  On  section,  the  fibrous  type  is  pearly  or  pinkish  white 
and  homogeneous,  while  in  the  adenomatous  type  the  glandular  areas 
can  be  distinguished  as  small  pink  dots.  Microscopic  examination 
reveals  large  areas  of  palely  stained  connective  tissue  often  with  myxoid 
degeneration,  interspersed  with  glandular  tissue  (Fig.  290).  The  glands 
are  unchanged  or  even  atrophic  in  the  fibrous  type,  while  in  the  adenoma- 
tous group  the  glands  are  more  numerous  and  stain  more  deeply,  and 
often  show  cA^stic  degeneration.  In  these  cases  there  is  a  tendency 
toward  papillary  formation  on  the  part  of  the  gland  epithehum.  These 
changes  explain  the  proneness  of  the  fibro-adenomatous  group  to  undergo 
malignant  change.  Occasionally,  the  fibrous  tissue  tends  to  grow  into 
the  cysts,  giving  rise  to  the  so-called  intracanalicular  fibro-adenoma. 
These  resemble  very  closely  similar  formations  in  the  mixed  tumors, 
and  may  indicate  a  genetic  relation  to  them. 

Diagnosis.— Their  exquisite  encapsulation,  smooth  surface,  and  firm- 
ness suffice  to  identify  them.  The  slow  growth  of  the  tumor  and  the 
3  outh  of  the  patient  off'er  additional  evidence.  Often  normal  gland 
lobules  in  the  breasts  of  young  women,  particularly  in  those  recentl}^ 
married  or  subject  to  sexual  excitement,  are  mistaken  for  fibro-adenomas. 
Usually,  careful  examination  will  reveal  other  nodules  in  the  same  or  the 
other  breast.  A  diagnostic  sign  often  emphasized  consists  in  placing 
the  flat  hand  upon  the  breast.  If  no  tumor  is  felt  in  this  way  the 
nodule  may  be  regarded  as  glandular.  Occasionally,  fibro-adenomas 
are  multiple,  in  which  case  they  are  usually  of  the  intracanalicular 
variety.  They  may  be  difi^erentiated  from  mixed  tumors  onl}^  after  the 
latter  have  undergone  rapid  enlargement.  Their  painlessness  and  definite 
encapsulation  will  distinguish  them  from  inflammatory  nodules.  From 
carcinoma  they  are  diff'erentiated  by  their  encapsulation.  Occasionally, 
these  tumors  undergo  malignant  change.  I  have  examined  two  such 
cases  in  women  under  thirty,  in  both  of  which  it  was  possible  to  detect 
the  change  at  the  operating  table. 

Treatment. — Removal  is  advisable  in  all  cases  on  account  of  the  mental 
distress  they  cause  the  patient  and  the  possibility  of  malignant  change. 
This  is  easily  accomplished  under  local  anesthesia  by  splitting  the  capsule 
and  turning  out  the  tumor.  Care  should  be  taken  to  maintain  asepsis, 
as  the  deep  wound  is  prone  to  infection  on  account  of  the  low  resist- 
ance of  the  loose  fatty  tissue.     If  it  is  desirable  to  avoid  a  scar  over  the 


sj:.\ /!./■:  I'.iRESciiYM.iroi  s  ini'Lki koriir 


4(H 


exposed  portion  of  the  iiianinia  an  incision  nia\  he  made  alon^  the  told 
of  the  lower  ed^e  of  the  breast  after  the  method  of  Warren,'  the  breast 
ma\  be  elevated  and  tin  rumor  excised  from  behind.  This  operation 
is  of  jireater  niaiiiiiriuli-,  and  sa\i-  in  txct  priDiKil  mstanccs  wdl  nor  be 
st'lecricl. 

Chronic  Interstitial  Mastitis.  Nor  infViMiiu  nrl\  intersririal  changes 
in  the  mamma  simulate  a  tumor.  There  is  an  increasing  diffuse  hard- 
ness of  rlu-  cnrire  breast,  in  which  inter- 
stitial tissue  is  chief!)-  concerned,  though 
the  «ilandular  element  shows  some  in- 
crease, and  c\  st  formation  is  common. 
This  t\pe  is  most  often  seen  in  nervous 
unmarried  women  about  thirty  _\'ears 
of  age.  The  entire  gland  is  converted 
into  a  firm  resistant  mass  (Fig.  291). 
Usuall\-  cysts  can  be  made  out  with 
the  naked  eye.  Microscopicalh',  the 
picture  closelv  resembles  fibro-adenoma. 
Sometimes  the  lumen  of  the  gland  are 
filled  with  epithelial  cells,  which  are, 
how'ever,  degenerated  forms,  and  not 
cells  of  abnormal  development. 

Histologically,  these  structures  re- 
semble closeh'  some  types  of  senile 
parenchimatous  hypertrophies,  but  in 
interstitial  mastitis  the  process  is  es- 
sentialh"  an  interstitial  one  attended 
hv   cvst    formation,     though   papillarj- 

proliferation  is  not  unknown.  The  age  of  incidence,  the  extent  of 
the  process,  and  the  slight  liability  to  become  malignant  are  the 
chief  reasons  for  regarding  them  as  a  separate  group.  The  breast 
ma\'  require  excision,  but  the  removal  of  the  axillary  contents  and 
sacrifice  of  the  pectoral  muscle  are  not  justified. 

Senile  Parenchymatous  Hypertrophy.- — Midway  between  the  pre- 
viouslv  mentioned  inflammatory  diseases  of  the  breast  and  carcinoma 
stands  a  group  of  changes  which  have  been  designated  as  senile  paren- 
ch\  matous  hypertrophy  by  Bloodgood.^  This  is  the  most  expressive 
term  ^'et  suggested  for  the  condition,  because  the  senile  changes  are 
observed  in  the  connective  tissue  and  in  a  part  of  the  glandular  tissue, 
while  in  other  portions  epithelial  proliferation  alone  is  present. 

^  Jour.  Amer.  Med.  Assoc,  1905,  xlv,  149. 
-  Schimmelbusch,  Arch.  f.  klin.  Cliir.,  1892,  xliv.  117. 
^  Surg.,  Gynec,  and  Obst.,  1906,  iii,  721. 
26 


Interstitial  mastitis  involving  the 
entire  gland.  Numerous  cysts  can 
be  seen. 


402  TUMORS  OF  THE  MAMMARY  GLAND 

The  disease  occurs  most  frequently  about  the  menopause,  usually 
between  forty  and  fifty  3^ears  of  age,  but  it  is  sometimes  seen  in  younger 
women.  It  is  most  frequently  seen  in  nulliparas,  but  not  mfrequently 
in  multiparas.  It  must  be  regarded  as  composed  of  a  number  of  con- 
ditions; according  to  Bloodgood,  these  are  phases  of  a  continuous 
process.  Various  lesions  are  present,  but  their  inter-relations  are  difficult 
to  determine. 

Bloodgood  speaks  of  an  adenomatous  (Fig.  292),  an  ectatic  (Fig.  293), 
and  an  adenocystic  stage.  In  the  first  the  glandular  elements  are  in- 
creased  so  as  closely  to  resemble  the  adenofibromas.      In  the  ectatic 

Fig.  292 


Adenomatous   type   of  senile   parenchymatous   hypertrophy:      a,   gland    epithelium; 
h,  basement  membrane;  c,  connective  tissue. 

Stage  cysts  of  varying  size  (Fig.  294)  are  formed  without  marked  pro- 
liferation of  the  epithelium  (Fig.  295),  while  in  the  adenocystic  stage 
(Fig.  296)  the  glandular  elements  tend  to  proliferate  (Fig.  297).  About 
one-half  of  these,  according  to  Bloodgood,  become  malignant.  The 
second  stage,  it  seems  to  me,  represents  a  benign  group  with  no  tendency 
to  malignancy,  resembling  in  this  the  glandular  ovarian  tumors;  the 
adenocystic  group  tends  to  invade  the  surrounding  tissue  rather  than 
to  form  a  secretion,  and  corresponds  to  the  papillary  ovarian  cysts. 
The  adenocystic  stage  of  Bloodgood  corresponds  to  Schimmelbusch's 
type. 


Fig.  293 


Ectatic   t3-pe   of  senile    parench}matous    h\  [urrrophy.      Xmnerous   smooth-walled 
cysts  are  scattered  throughout  the  eland. 


Fig.  294 


Ectatic  stage  of  senile  parenchimatous  hypertrophy:  c,  cyst  with  slightly  proliferated 
epithelium;  b,  cyst  with  unchanged  epithelium;  a,  fibrous  papilloma  projecting  into  a  cyst. 


404 


TUMORS  OF  THE  MAMMARY  GLAND 


When  malignant  changes  occur,  the  epithehal  walls  of  a  dilated  tubule 
begin  to  proliferate  and  form  papillary  excrescences,  which  may  fill 
the  entire  cyst  with  newly  formed  cells.  Sometimes  the  proliferation 
becomes  more  active,  the  surrounding  tissue  is  invaded,  and  the  malig- 
nant transformation  is  complete.  The 
crucial  point  is  not  the  degree  of 
multiplication  of  the  cells,  but  their 
relation  to  the  basement  membrane; 
when     the    malignant     stage     is    ap-  ,' 

proached     the     basement     membrane  --'    , 

disappears  (Fig.  298).     It  is  impossible 
to    say     with     what    frequency    this 


Fig.  296 

•X. 


\ 


Fig.  295 


fe^«> 


High-power  drawing  of  cyst,  showing  the 
character  of  the  epitheUum. 


i^ 


Adenocystic  stage  of  senile  parenchy- 
matous hypertrophy.  The  larger  cyst 
shows  papillary  formations  in  its  interior. 


metamorphosis  takes  place.  In  the  ectatic  type  the  secretory  function, 
as  I  have  already  indicated,  is  more  active  than  the  proliferative,  and 
invasion  of  the  basement  membrane  rarely  occurs. 

Diagnosis, — Senile  parenchymatous  hypertrophy  differs  from  adeno- 
fibroma  in  being  more  diffuse  and  in  occurring  usually  later  in  life. 
Interstitial  mastitis  involves  the  entire  breast  and  occurs  in  younger 
women.  On  section,  these  senile  breasts  are  whitish,  with  pink  dots 
occurring  in  groups.  When  the  ectatic  stage  is  reached,  cysts  of  vary- 
ing sizes  are  scattered  throughout  a  pinkish  fibrous-tissue  background. 


Fig.  297 


\^!^ 


'"''"'^cct^-'^i; 


7^<Jv. 


'-'■"    .^"r^-^^ 


Adenocystic  type  of  senile  parenchymatous  hypertroph}',  showing  a  larger  c\'st  without 
proliferation  of  the  epithelium,  while  the  others  are  filled  with  cells. 


Fig.  298 


V 

^ 


\9    >:='«   "^J^ 


© 


(?*' 


^sge.e.^0  --„-*3^-. 


s?:^ 


^^<^&e 


Area  in  senile  parenchimatous  hypertrophy,  in  which  glands  have  invaded  the  sur- 
rounding connective  tissue,  indicating  that  a  malignant  stage  has  been  reached. 


406  TUMORS  OF  THE  MAMMARY  GLAND 

The  cysts  are  usually  smooth-walled,  but  may  show  papillary  excres- 
cences. Landau  believes  this  type  is  never  associated  with  carcinoma, 
in  which  opinion,  as  I  have  already  said,  I  agree.  In  the  adenocystic 
type  the  pinkish  dots  are  intermixed  with  very  minute  cysts.  The 
cellular  element  is  more  abundant  proportionately  than  in  the  other 
types.  When  the  malignant  stage  is  reached  the  pinkish  points  are 
replaced  by  the  grayish  white  of  the  cancer  plugs,  and  the  stroma  is 
much  denser  on  palpation  and  section.  Often  an  incision  into  the  tumor 
at  the  time  of  operation  is  necessary  in  order  to  determine  the  diagnosis. 
In  such  cases  the  incision  of  Warren  is  to  be  recommended,  since  it  gives 
a  free  access  to  the  entire  gland.  Many  surgeons  employ  frozen  sec- 
tions at  the  time  of  the  operation  for  the  purpose  of  making  a  diagnosis. 

It  is  not  uncommon  to  find  nodules  of  firmer  consistency  in  women 
approaching  the  menopause.  These  are  often  multiple  and  frequently 
bilateral,  and  are  usually  well  circumscribed;  they  are  not  so  dense  as 
true  senile  hypertrophy.  These  areas  disappear  if  let  alone.  They 
seem  to  correspond  to  similar  states  at  puberty  or  from  sexual  excite- 
ment, and  to  be  the  response  to  changes  incident  to  the  menopause 
when  also  other  sexual  functions  are  sometimes  exaggerated.  I  have 
seen  this  condition  present  in  patients  with  fibroids  of  the  uterus  and 
disappear  when  the  pelvic  tumors  were  removed. 

Treatment. — When  a  nodule  is  discovered  in  a  senile  breast  it  is  a 
proper  object  for  surgical  interference.  If  the  condition  is  a  cystic  one 
the  excision  of  the  cyst-bearing  area  is  sufficient.  Should  the  cystic 
contents  be  hemorrhagic  the  complete  removal  of  the  breast  is  the  safer 
procedure.  If  the  adenocystic  type  is  present,  the  removal  of  the  entire 
breast  is  indicated.  If  areas  are  discovered  which  have  already  under- 
gone a  malignant  change,  the  axilla  should  be  cleared  out  at  once. 

Tuberculosis. — Tuberculosis  of  the  breast  is  regarded  as  a  rare  disease, 
but  the  frequency  with  which  it  is  found  in  the  laboratory  after  radical 
operation  makes  one  believe  that  the  disease  deserves  more  considera- 
tion than  it  usually  receives.  Though  occurring  most  frequently  in 
women  between  the  ages  of  twenty-five  and  thirty-five  years,  it  has 
been  observed  in  older  women  and  rarely  in  men.  The  disease  may 
be  primary,  but  is  generally  secondary  to  tuberculous  foci  elsewhere. 
The  danger  of  unnecessary  radical  operation  make  its  chnical  diagnosis 
of  importance. 

Forms. — It  occurs  in  several  forms:  (i)  As  cold  abscesses;  (2)  as 
sohtary  tubercles;  (3)  as  disseminated  nodules;  and  (4)  as  conglomer- 
ated masses. 

Modes  of  Infection. — Infection  may  take  place  in  several  ways:  (i) 
By  extension  from  a  diseased  rib  or  sternum,  or  from  a  tuberculous 
pleurisy;    (2)    from   lymph    glands,   particularly    those   situated    at   the 


ri  ur.Rci  i.ns/s  or  ////■:  hreist  MM 

antciioi  ;i\ill;ir\  IxmU  i.  Korm^'  \\;is  tin-  hist  lo  cniph;isi/.f  this  iiiodt- 
of  iiitrction,  A\\(\  m.iin  icrtiii  ohsc-rvcrs  sustain  his  opinion;  (jj  infec- 
tion m.i\  lake  \A.\cv  ihioiii^h  the  nipple,  rhoniih  this  is  rare;  '4)  it  is 
USiialK  t  lansinii  IihI  thioui^h  the  hhxxl  eiiircnt ,  and  main  ot  the  ii-|-)oi'recl 
c;isi'S  ;ire  Hist  noud  tluimLi,  hu'iainni.  It  ahiach  |)i(sent,  the  disease 
prosiiissis  inoie  lapulh    during  tins  |>tii()d. 

Symptoms  and  Course.  I  In-  course  is  usuall\  chronic.  Dull,  aching  pain 
nia\  he  the-  Hist  s\niptoni,  or  a  nodule  ina\  he  discovered  Hist.  I' re- 
quentl\  ,  a  nuinlnr  of  nodules  are  jz;rouped  in  one  (juadrant  of  the  ^land, 
or  they  may  he  diffuse.  \\\l'  nodules  are  Hrm,  not  freel\'  movable, 
and  moderately  tender  on  pressure.  After  rlu-  initial  round-celled 
iiiHIrration  subsides  and  partial  encapsulation  takes  jilace  the  mobility 
is  <2;reater.  1  he  various  nodules  may  remain  discrete,  or  the\'  may 
coalesce  especially  in  patients  of  low  vitality.  After  a  time  the  centre  of 
one  or  more  of  the  nodules  may  caseate  and  liquefy.  1  he  skin  becomes 
reddened  and  adherent,  and  may  be  perforated  so  that  a  permanent 
fistula  is  formed.  The  nodular  mass  may  attain  the  size  of  an  orange 
or  the  breast  ma\'  be  smaller  than  normal  on  account  of  the  formation 
of  fibrous  tissue.  In  these  cases  the  nipple  is  frequenth'  retracted, 
particularly  after  extensive  caseation  and  fistula  formation.  In  the 
early  stages  the  fascia  is  free,  but  it  may  become  attached  later.  En- 
largement of  the  h'mph  glands  may  precede  the  mammary  disease, 
and  even  when  not  primarily-  involved  they  are  soon  infected.  1  he}' 
vary  in  size  from  a  bean  to  a  hick:or\'-nut.  They  sometimes  become 
caseated  and  form  fistulas.  When  the  disease  has  existed  for  some 
time  there  may  be  an  evening  rise  of  temperature. 

Diagnosis. — When  there  is  evidence  of  tuberculosis  elsewhere  he 
possibility  of  similar  mammary  disease  should  always  be  borne  in  mind. 
It  must  not  be  forgotten,  however,  that  malignant  disease  of  the  breast 
nia\'  find  its  chief  expression  in  a  slowl}'  growing  lung  metastasis  which 
ma)'  be  mistaken  for  a  primary  tuberculosis.  The  mammary  changes 
in  tuberculosis  may  resemble  carcinoma,  but  where  there  is  a  sinus, 
its  crateriform  opening  and  thin  watery  discharge  are  sufiiciently 
characteristic  to  declare  the  tuberculous  nature  of  the  affection.  In 
the  conglomerate  t\'pe  there  is  a  uniform  moderate  hardening  of  the 
mammar)'  tissue  with  a  varj^ing  degree  of  pain,  and  the  patient  is  usuall\' 
a  young  woman.  The  mass  does  not  attain  the  hardness  characteristic 
of  carcinoma  nor  do  the  axillary  glands  become  so  hard.  In  women 
of  middle  life,  not  the  subject  of  demonstrable  tuberculosis  elsewhere, 
a  macroscopic  section  of  the  tumor  during  the  course  of  the  operation 
may  be  necessar\"  for  diagnosis.    The  presence  of  caseated  areas  and  the 

'  Lehrbuch.  d.  spec.  Cliir.,  I  Iirschwald,  Ht-rlin,  1893,  '^'"l-  !•• 


408  TUMORS  OF  THE  MAMMARY  GLAND 

absence  of  the  characteristic  unit  lesion  of  carcinoma  are  sufficient 
to  distinguish  the  two  diseases.  A  microscopic  diagnosis  from  a  frozen 
section  will  rarely  be  needed.  The  co-existence  of  the  two  diseases  has 
been  reported. ^ 

Tuberculosis  may  be  distinguished  from  actinomycosis  by  the  absence 
of  the  characteristic  canary  yellow  granules  and  of  the  indurated  yellow 
skin. 

Fibro-adenomas  are  usually  single  and  clearly  encapsulated,  and 
there  is  no  glandular  involvement.  Interstitial  mastitis  occurs  in  more 
rugged  neurotic  young  women,  and  there  is  no  glandular  involvement. 
The  entire  breast  is  enlarged  and  more  dense  than  in  tuberculosis, 
and  the  cysts  are  more  tender  than  the  softened  areas  in  tuberculosis. 
Aspiration  is  to  be  practised  in  case  of  doubt.  On  section,  the  tubercu- 
lous areas  are  whitish  or  grayish,  with  usually  cheesy  areas  in  the  centre. 
The  newer  tests,  Moro's  and  Calmette's,  are  too  recent  to  permit  of  a 
proper  estimate  of  their  value.  The  bacilli  may  sometimes  be  demon- 
strated in  the  pus,  though  the  search  has  frequently  been  fruitless  even 
in  the  excised  gland;  or  inoculation  of  guinea-pigs  may  be  necessary  to 
prove  the  presence  of  the  disease. 

Prognosis. — When  the  disease  is  primary  the  prognosis  is  good.  When 
secondary,  the  prognosis  depends  upon  that  of  the  primary  lesion. 

Treatment. — When  an  abscess  is  formed  without  extensive  infiltra- 
tion, incision,  curettage,  and  drainage  (Warren),  or  incision  and  tampon- 
age  with  iodoform-glycerin  or  iodoform-ether  may  be  employed.  When 
there  is  much  infiltration,  excision  will  give  satisfactory  results.  Rodman 
emphasizes  the  fact  that  since  this  disease  usually  occurs  in  young  women, 
the  gland  should  be  dealt  with  as  conservatively  as  possible,  because 
of  the  decreased  chances  for  matrimony  after  complete  removal.  When 
extensively  involved,  the  entire  gland  may  require  removal,  but  the 
radical  operation  as  employed  in  carcinoma  is  never  justified. 

Mixed  Tumors.2 — Scattered  through  the  literature  are  a  great  variety 
of  terms  applied  to  tumors  of  the  mammary  gland,  such  as  cystic  sar- 
coma, adenosarcoma,  cystosarcoma,  sarcoma  myxomatodes,  chondro- 
sarcoma— all  indicating  combinations  of  epithelial  and  connective  tissue. 
The  researches  of  Wilms  have  done  much  to  simplify  the  conception 
and  terminology  of  these  tumors,  which,  it  has  long  been  known,  have 
clinically  much  in  common. 

Wilms  groups  these  heterogeneous  tumors  together  under  the  term 
"mixed  tumors."  He  regards  their  formation  as  due  to  some  dis- 
placement of  tissue  in  the  anlage  of  the  mammary  gland.     He  calls 

1  Warthin,  Amer.  Jour.  Med.  Sci.,  1899,  cxviii,  25. 

2  Periductal  Myxoma,  Warren,  Jour.  Amer.  Med.  Assoc,  1905,  xlv,  149. 


MIXED  r  I  MORS  or   Till:   M.I  MM. IKY  (.L.I  SI)  409 

iittciition  to  tin-  tacr  that  tin-  mammaiy  ^land  is  not  foiiiicd  from 
the  skin  as  such,  hut  that  the  skin  covering  the  ^land  and  the  j^land 
itself  are  derived  from  thi-  primary  epihhistic  hiyer,  a  point  which  is 
certainly  well  taken. 

In  other  words,  at  the  time  the  anla^e  of  the  ^htnd  appears,  the 
skin  is  not  yet  formed,  and  a  displacement  of  epihhistic  cells  is  likelv 
to   include   cells   which   would   become  glandular  and   also   cells   which 

Fig.  299 


A- 


•    ^       -,;,?^i^.' *•-.:-      ,'-  /I  4.. 


#3^//: 
;-.?^^ 


Section  of  a  mixed  tumor  of  the  breast.     The  fibrous  tissue  forms  papillary 
projections  within  the  epithelium-lined  spaces. 

would  become  epidermal.  When  this  displaced  tissue  begins  to  pro- 
liferate, columnar  and  squamous  epithelial  cells  ma}'  develop  side  by 
side.  These  may  form  cystic  spaces  if  the  cells  produce  a  secretion, 
or  fibrous  tissue  ma}-  form  papillary  masses  which  fill  the  cysts  and 
produce  an  intracanalicular  fibro-adenoma  or,  if  the  connective  tissue 
is  more  cellular,  a  sarcoma  phyllodes  (Fig.  299)  of  the  older  writers. 
The  connective  tissue,  being  also  embryonal,  continues  to  produce 
tissue  which  is  more  or  less  primitive  in  character.     In  this  way  m\xoid 


410 


TUMORS  OF  THE  MAMMARY  GLAND 


and  sarcoma-like  tissue  is  produced,  and  each  of  these  may  approach 
more  or  less  the  structure  of  adult  connective  tissue.  All  of  these  tissues 
may  be  present  in  varying  amounts  and  with  them  may  be  intermingled 
glands  more  or  less  typical,  all  combining  to  make  a  most  varied  picture. 
Not  infrequently  areas  typically  endotheliomatous  fFig.  300)  are 
observed,  though  not  with  the  same  regularit}'  nor  in  the  same  degree 
as_in  the  mixed  tumors  of  the  parotid. 

Fig.  300 


e;i^ 


*  ^^'  ~^  <  /,; ;  f " ;  .^ '  '•  '3.^^ 

Endotheliomatous  area  from  a  mixed  tumor  of  the  breast. 


This  hypothesis  seems  to  dispose  of  most  of  the  difficulties  which 
have  heretofore  attended  the  attempt  to  classify  these  tumors.  They 
correspond  in  general  to  the  mixed  tumors  in  being  benign,  notwith- 
standing their  apparently  sarcomatous  structure.  The  fact  that  they 
are  separated  sharply  from  the  surrounding  tissue  has  been  thought 
to  indicate  that  they  are  derived  from  structures  independent  of  the 
gland.  In  many  of  these  tumors,  areas  which  resemble  the  intra- 
canalicular  adenofibromas  are  seen,  and  indicate  a  possible  relation- 
ship between  the  two  groups  of  tumors. 

Clinical  Course. — Mixed  tumors  of  the  mammary  gland  are  usually 
seen  in  adult  life,  cases  having  been  reported  in  patients  from  twenty- 
eight  to  seventy-two  j^ears  of  age;  and  in  some  instances  small  tumors 


Cl.l.MC.Il.   C.Ol  KSli  Ul     n  MORS  1)1     TIU.    M.IMM.IKY   I.L.I  \  I)       111 

Iki\c-  Ihcii  ()I)sci\  icI  cvtii  earlier.  \\  Ikii  hist  noticed  rhev  are  painless 
nodules,  and  after  a  period  var\in^  from  one  to  fifteen  or  more  \ears, 
they  take  on  a  more  rapiil  growth.  rsiiall\  when  the  patient  seeks 
advice  the  tumor  has  attained  some  si/e,  is  re^uhir  (  Fij^.  ^OIj  or  hos- 
selated  (  Ki^.  ^02)  in  outhne,  and  of  varvinji;  consistencw  Tense,  elastic, 
ami  cystic  areas  are  interminuled.  The  rumors  are  not  painful,  are 
heeiy    mo\ahK.   and   the   a.\inar\     l\rnphatics    remain   unaffected.      Like 

Fk;.  101 


Mixed  tumor  of  the  breast,  showing  nodulations  of  the  mass  and  a  cyst  immediately 

below  the  nipple. 


the  mixed  tumors  of  the  parotid,  the\'  may  exist  without  increase  in 
size  for  many  \ears  or  may  enlarge  ver^-  slowly.  Sooner  or  later  x\\ty 
begin  a  sudden  growth,  infiltrate  the  surrounding  tissue,  and  assume 
the  cluneal  characters  of  a  sarcoma  or  endothelioma. 

Diagnosis.— They  resemble  in  form  the  cellular  t\pe  of  carcinoma, 
but  the  varying  consistency  and  particularl\-  the  complete  encapsula- 
tion are  usually  sufficient  to  distinguish  the  mixed  tumors.  The  absence 
of  lymphatic   enlargement   and   the    usual    history   of  slow  growth   are 


412  TUMORS  OF  THE  MAMMARY  GLAND 

other  signs  which  emphasize  the  diagnosis.  If  doubt  exists  an  incision 
into  the  tumor  at  the  time  of  operation  will  clear  up  the  matter.  The 
mixture  of  pink  homogeneous  myxoid  tissue,  with  glandular  and  cystic 
dilatations,  and  particularly  cartilage,  if  present,  makes  a  picture  never 
seen  in  carcmoma. 

In  the  light  of  the  studies  of  Wilms,  the  relation  of  these  tumors 
to  sarcomas  must  be  considered  anew;  in  fact,  nearly  all  the  so-called 
sarcomas  of  the  breast  should  be  classed  among  the  mixed  tumors. 
This  being  the  case,  the  number  of  true  sarcomas  of  the  breast  becomes 
very  small,  too  small,  in  fact,  to  permit  us  to  form  a  definite  clinical 
picture.     So  far  is  this  statement  true,  that  all  the  tumors  previously 

Fig.  302 


Mixed  tumor  of  the  breast,  showing  the  nipple  carried  on  the  summit. 

reported  as  sarcomas,  which  have  been  subjected  to  reexammation, 
have  been  found  to  be  mixed  tumors.  Usually  some  portion  of  the 
rapidly  growing  tumor  shows  evidence  of  an  origin  within  a  mixed 
tumor.  Cysts  are  likely  to  be  present,  and  even  when  absent,  spaces 
filled  by  newgrowth  of  tumor  masses  can  be  made  out.  These  are 
the  sarcoma  phyllodes  of  the  older  writers. 

Treatment. — Since  mixed  tumors  do  not  affect  the  glands  and  metas- 
tasis has  not  been  observed,  they  are  benign  tumors,  and  simple  shelling 
out  is  sufficient  treatment.  Like  other  mixed  tumors,  they  may  undergo 
malignant  change,  and  thorough  prophylactic  removal  should  always  be 
practised.  After  evidence  of  malignant  change  appears,  the  treatment 
is  that  of  sarcoma  and  endothelioma. 


R.I  RE  TV  MORS  Of  Till:    HRE.IST 


41  :^ 


Rare  Tumors  of  the  Breast.  Lipoma.  LiponKi  of  the  breast  is  an 
Lincomiiu)!!  artccrion.  latry  tmnors  are  observed  about  rbe  axilla, 
about  the  outer  border  of  the  fi,laiul,  and  below  the  clavicle,  but  these 
should  not  be  classed  as  niaiiiniar\'  lipomas.  Ihe  gland  in  man\'  instances 
may  be  compost-d  hir<j,el\  ol  iiiassis  of  fat;  but  this  tondition  does  not 
constitute-  li|ioiiia.      I  i  in-  nianiiiiai\    lipomas  which  dis|)lace  the  glandular 

Ik;.  303 


Papilloma  of  tlie  nipple. 


tissue  do  sometimes  occur.  They  may  project  behind  the  gland, 
raising  it  up  (retromammary  Hpomasj,  or  they  ma\-  grow  over  the 
surface  of  the  gland. 

Papilloma. — Papillomas  (Fig.  303)  of  the  nipple  are  sometimes  observed. 
They  begin  as  a  cauliflower  proliferation  of  the  epithelium  of  the  nipple 
and  ducts.  From  the  weight  of  the  tumor  the  base  of  the  nipple  be- 
comes attenuated  and  a  long  pedicle  may  result. 


414  TUMORS  OF  THE  MAMMARY  GLAND 

Myxoma. — This  is  even  more  rare  than  Hpoma.  When  myxoid  tissue 
is  observed  it  is  associated  with  other  tissue  forming  a  part  of  a  mixed 
tumor;  or  more  frequently  appears  as  a  secondar}"  degeneration  of 
these  tumors.  It  has  been  described  as  occurring  in  sarcomas.  An 
investigation  of  the  subject  is  needed  to  determine  if  myxoid  tissue 
ever  occurs  in  the  mammary  gland  independent  of  mixed  tumors.  In 
every  case,  when  myxoid  tissue  is  encountered  in  a  breast  tumor,  care- 
ful examination  should  be  made  to  determine  its  relationship  to  other 
tumor  tissue  which  may  possibly  be  present  in  very  small  amounts. 

Angiomas. — These  are  rare,  but  cases  of  extensive  vascular  tumors 
involving  the  substance  of  the  mammary  gland  have  been  recorded. 
Simple  capillary  nevi,  common  over  the  chest,  are  frequently  observed 
in  the  skin  covering  the  mammary  gland,  but  as  they  involve  the  skin 
only,  they  should  not  be  classed  with  diseases  of  the  breast.  They 
differ  in  no  way  when  found  in  this  situation  from  nevi  occurring 
elsewhere. 

Chondroma  and  Osteoma. — Chondroma  and  osteoma  occur  occasionally 
as  parts  of  mixed  or  teratoid  tumors  of  the  mammary  gland,  and  not  as 
independent  tumors. 

Atheromatous  Cysts. — Atheromatous  cysts  may  occur  in  the  skin  of  the 
mammary  gland.  They  do  not  differ  from  similar  structures  observed 
in  other  regions. 

Diagnosis. — The  rarity  of  these  tumors  makes  a  detailed  considera- 
tion of  their  differential  diagnosis  unnecessary.  The  lipomas  are  soft, 
semifluctuating,  lobulated  tumors.  The  myxomas  will  scarcely  be 
diagnosticated  except  on  exploratory  incision,  when  their  pale,  pink, 
homogeneous,  glistening  surface  is  characteristic.  The  co-existence 
of  other  tissue  is  frequently  a  laboratory  problem.  The  angiomas  are 
detected  by  their  color,  their  compressibility,  and  their  disposition 
promptly  to  assume  the  former  size  when  the  pressure  is  removed. 
Chondromas  and  osteomas  may  be  suspected  from  their  density,  and 
when  present  there  is  usually  evidence  sufficient  to  warrant  the  diag- 
nosis of  the  mixed  tumors,  of  which  these  tissues  often  form  a  constituent 
part.  Isolated  tumors,  globular  and  semifluctuating,  should  raise  the 
question  of  a  possible  atheromatous  cyst. 

Treatment. — Excision  of  all  these  varieties  is  indicated,  but  radical 
operation  is  not  permissible.  When  any  of  these  tissues  form  a  con- 
stituent part  of  some  tumor,  the  treatment  naturally  is  that  of  the 
tumors  to  which  they  belong.  Angiomas,  not  being  encapsulated,  do 
not  permit  of  shelhng  out.  Multiple  hgation  has  been  practised,  but 
because  of  their  rarity  there  has  been  no  occasion  for  the  formulation 
of  a  modern  technique. 


s.iRcoM.i  or  Tin:  hke.ist  415 

Sarcoma.  Snnomas  of  the  hiciisr  air  nor  common,  hiii  all  kinds 
ha\i-  luiii  iipoi  ticl.  I  In-  spmdK-cclicd  variety,  eitlni  alom  or  asso- 
(.•laricl  with  sonu'  oilur  cell  t\|)is,  is  tin-  most  common.  Mvxonia  is 
not  uncoinmonh  associated  with  sanomas,  oi  appear  as  a  sc'C()n(lar\' 
chanm'.  In  man\  ol  rlu-  cases  x\\v  oii<i;in  of  tin-  m\  xoid  tissue  can  he- 
traced  to  peiiducral  myxomas,  whicli  are  proliahh  mixed  tumors.  J  he 
entire  Hfe  history  of  hreast  sarcomas,  so  called,  resembles  so  closelv 
tile  course  of  the  mixed  rumors  of  the  parotid  that  it  is  impossible  not 
to  accept  Wilms'  view  as  to  their  similar  oiif^m.  In  very  extensive 
growths  such  a  relation  cannot  be  demonstiared,  and  it  is,  therefore, 
necessary  to  admit  the  probability  of  an  independent  group. 

Frequency.  In  rlu-  older  statistics  lo  per  cent,  was  given  as  the  usual 
proportion  of  breast  sarcomas.  More  recently,  owing  to  more  careful 
examination,  this  percentage  has  been  reduced.  Rodman^  places  it 
at  2.7  per  cent.,  while  Bloodgood-  found  but  14  cases  of  sarcoma  in  694 
mammary  tumors.  Poulsen''  reports  33  cases  in  3:55  mammar\-  tumors. 
They  are  rare  before  the  twenty-fifth  ^ear,  though  the\'  have  been  seen 
at  a  much  earlier  age.  The}'  are  most  frequent  when  the  gland  is  most 
active,  but  they  have  been  observed  after  the  gland  has  become  quiescent 
from  age.  These  statements  must  all  be  taken  with  reservations,  because, 
as  I  have  said  before,  all  the  older  literature  is  valueless  on  account 
of  the  looseness  with  which  the  terms  were  applied,  due  to  the  failure 
to  make  a  careful  histological  diagnosis.  A  new  statistical  collection 
is  greatly  needed. 

Secondary  Changes. — Any  secondary  change  to  which  sarcoma  is  sub- 
ject may  take  place  here.  Cystic  degeneration  with  or  without  hemor- 
rhage is  common,  the  cysts  being  due  to  retention  of  secretion  from  occlu- 
sion of  ducts,  or  possibh'  to  degenerative  processes;  though  it  seems 
possible  that  these  cyst  formations,  instead  of  being  degenerations,  are 
evidences  of  origin  from  a  mixed  tumor. 

Clinical  Course. — Sarcomas  of  the  breast  may  grow  ver^-  slowly  for 
a  time,  then  suddenly  show  rapid  development,  or  may  grow  rapidh' 
from  the  beginning.  Usually'  they  remain  encapsulated  and  show  no 
disposition  to  infiltrate  the  surrounding  tissue,  but,  instead,  displace 
the  gland.  They  may  appear  in  any  part  of  the  gland  and  are  nearly 
always  single,  rarely  bilateral.  The  physical  characteristics  vary.  Gen- 
erally they  are  dense  and  elastic,  but  the  cellular  varieties  are  soft.  If 
cysts  have  formed,  the}'  are  fluctuating.  When  hemorrhage  occurs 
into   the   substance   or   into   preformed  cysts,  the    tumors    may   enlarge 

'  Jour.  Amer.  Med.  Assoc,  191 1,  Ivi,  793. 

^  Kelly  and  Noble,  Gynecology  and  Abdominal  Surgery,  Saunders,  Philadelphia, 
1908,  vol.  ii. 

^Archiv  f.  klin.  Chir.,  iSgi,  xlii,  593. 


416  TUMORS  OF  THE  MAMMARY  GLAND 

suddenly.  Excessively  rapid  growth  is  the  rule  when  they  are  asso- 
ciated with  pregnancy. 

Creighton^  has  given  a  graphic  word  picture  of  breast  sarcoma  in 
the  following:  "A  tumor  of  the  breast  will  be  diagnosticated  sarcoma 
if  it  bulges  out  as  a  globular  or  ovoid  or  spherical  mass  carrying  the 
nipple  erect  upon  its  summit  or  at  one  side;  distending  the  skin,  which 
is  often  red  or  livid,  glazed,  thin,  and  ready  to  burst,  having  a  definite 
rounded  contour  wherever  it  can  be  felt,  nodulated  or  lobed,  feeling 
tense  or  elastic,  of  rapid  growth;  or,  if  it  has  burst  through  the  skin, 
making  a  bleeding  fungus  with  overhanging  edges,  or  a  fleshy  lobu- 
lated  knob  or  houton  covered  with  a  fleshy  pellicle.  On  section,  it  will 
be  found  uniformly  grayish  or  fleshy,  separated  into  definitely  rounded 
or  oval  lobes  or  into  convolutions,  with  a  lobulated  or  scalloped  margin, 
encapsulated,  vascular,  interspersed  with  areas  of  extravasated  blood 
or  of  blood  pigment,  or  with  opaque  yellowish  or  sand-colored  tracts,  or 
with  friable  necrotic  centres;  if  there  be  much  mamma  left,  it  will  be 
borne  upon  the  surface  of  the  tumor  at  one  or  more  sides  as  a  distinct 
stratum." 

Diagnosis. — Usually  the  changes  in  the  skin  over  the  tumor  furnish 
the  best  evidence  of  the  nature  of  the  growth.  These  changes  may  go 
on  to  ulceration,  though  this  is  less  common  than  in  carcinoma.  When 
it  does  occur  the  skin  is  destroyed  by  pressure  and  not  by  infiltration. 
Sarcoma  must  be  differentiated  from  fibro-adenoma  and  mixed  tumors. 
From  the  former  they  differ  in  coming  on  later  in  life,  in  being  single, 
unilateral,  not  so  freely  movable  within  the  capsule,  softer,  and  generally, 
of  more  rapid  growth.  The  skin  changes  above  noted  are  not  found 
in  fibro-adenoma.  Sometimes,  however,  tumors  are  encountered  which 
bear  a  general  resemblance  to  the  sarcomas,  but  are  complicated  by 
epithelial  growths;  glands  with  columnar  or  squamous  lining  which  may 
or  may  not  be  dilated  into  cysts.  The  interstitial  structure  may  be  com- 
posed of  connective  tissue  resembling  the  embryonal  type,  or  a  large 
area  may  be  distinctly  myxomatous.  The  latter  condition  has  been 
regarded  as  a  secondary  change,  but  the  encapsulation  and  the  asso- 
ciation of  several  types  with  epithelium,  together  with  their  clinical 
history,  make  it  seem  probable  that  Wilms  is  correct  in  classing  these 
forms  with  the  mixed  tumors  {q.  v.). 

No  doubt,  as  Billroth  insisted,  there  is  sometimes  a  change  from  the 
sluggish  encapsulated  tumor  into  the  typical  sarcoma,  just  as  an 
occasional  adenofibroma  becomes  a  malignant  epithelial  tumor.  The 
majority  of  sarcomas  of  the  breast  are  implanted  upon  some  preexistent 
tumor,  but  there  are  some  few  for  which  such  an  origin  cannot  be  demon- 

1  Cancers  and  other  Tumors  of  the  Breast,  Williams  and  Norgate,  London,  1902. 


c./Rc/.xoM.i  or  ■/■///■:  hri-.ist  417 

strattd.  riu-  vast  ni;t|()rit\  ot  these  breast  nmiors  at  some  period  of 
their  fi;ro\vth  are  heiii<;n,  and  to  disrinj2;uish  the  sta^e  of  the  disease 
IS  one  of  the  most  chfHeiilt  tasks  ol  the-  siii};eon.  I  he  slow  j^rowth, 
even  it  prom"essi\'e,  incheates  that  the  niahjiiiant  sta^e  has  not  l)een 
reached,  hut  w  luii  rapid  growth  or  sudden  enhir^ement  from  hemor- 
rhajie  ocein,  the  chsease  should  be  rej^arded  as  malif:;nant. 

Encephaloid  carcinomas  may  resemble  sarcoma  in  that  the\'  form 
large  roiuulcd  tumors;  hut  the  skin  is  usuall\'  more  deHnitel)  iinaded, 
and  the  encaiisulation,  so  marked  in  sarcoma,  is  not  obsei\'ed.  Lntil 
the  entire  subject  is  <i;one  over  in  the  light  of  recent  knowledge,  it  seems 
that  any  attempt  at  a  more  distinct  definition  of  the  border-line  between 
the  rapidly  growing  mixed  tumors  and  sarcoma  is  impossible.  The 
passage  quoted  from  Creighton  applies  equally  well  to  the  rapidly  grow- 
ing mixed  tumors,  and  show^s  how  little  we  may  expect  from  clinical 
evidence  in  the  solution  of  the  problem.  One  cannot  question  the 
sarcomatous  nature  of  those  rarer  tumors  which  suddenly  invade  the 
surrounding  tissue,  rapidh'  destro\'ing  life  by  extension. 

Treatment. — When  the  diagnosis  of  sarcoma  is  established  removal 
of  the  entire  breast  is  even  more  urgent  than  in  carcinoma,  owing  to 
the  disposition  to  recur  locally.  The  tendency  to  metastatic  formation 
is  not  great.  Much  discussion  has  been  held  over  the  ad\isability 
of  clearing  out  the  axilla  in  sarcoma.  The  majority'  of  operators  do 
so  rather  because  of  uncertainty  in  the  diagnosis  than  because  it  is 
regarded  as  essential.  The  capsule  should  be  dissected  from  the 
surrounding  tissue,  and  not  merely  opened  to  allow  the  tumor  to  be 
shelled  out. 

Operative  Results. — The  rapidh'  grownng  round-celled  t\pe,  when  they 
have  invaded  the  surrounding  tissue,  destroA'  life  in  a  short  time  by  local 
recurrence  and  extension,  but  the  endotheliomatous  type  sometimes 
disappears  even  after  recurrence.  Before  the  capsule  is  invaded,  the 
operative  results  are  as  given  for  the  mixed  tumors,  Poulsen^  report- 
ing jz,  per  cent,  cured  by  operation. 

Carcinoma. — Carcinoma  of  the  female  breast  furnishes  the  most 
convenient  subject  for  the  stud}'  of  carcinoma  in  general,  and  will 
repay  detailed  consideration  because  certain  principles  in  diagnosis  and 
treatment  and  much  of  the  clinical  terminolog}'  of  tumors  in  general 
are  based  upon  observations  of  these  growths. 

Incidence. — Age. — In  this  region,  as  elsewhere,  carcinoma  is  a  disease 
of  middle  life.  It  is  observed  most  frequently  in  the  fifth  decade,  and 
is  very  rare  before  tw^enty-five.  In  the  statistics  of  some  3000  cases 
approximately   6   per  cent,   occurred   before   the   thirtieth   year,   25   per 

'  Loc.  cit.  , 

27 


418 


TUMORS  OF  THE  MAMMARY  GLAND 


cent,  between  thirty  and  forty,  50  per  cent,  between  forty  and  fifty, 
and  10  per  cent,  between  fifty  and  seventy.  These  figures  are  suffi- 
ciently accurate  to  show  the  overwhelming  frequency  during  the  fifth 
decade. 

Sex. — Approximateh^  i  per  cent,  occur  in  the  male.^ 
Varieties. — In  discussing   the   clinical   behavior  of  carcinomas  of  the 
breast  it  is  convenient  to  divide  them  into  several  groups.     These  are 
not    entireh'    distinct,  since    transitional   and    mixed   varieties    are   not 
uncommon. 


Fig.  304 


Fig.  305 


«i^-. 


Scirrhous  carcinoma  of  the 
mamma,  showing  contraction 
of  the  fibrous  tissue  with 
retraction  of  the  nipple. 


Carcinoma  in  the    base  of  the   nipple   in  a  mamma 
which  has  been  largely  replaced  by  fat  lobules. 


SciRRHUs. — For  the  tumor  about  to  be  described  the  term  "scirrhus" 
was  coined,  and  likewise  the  word  "cancer"  itself.  These  words  indicate 
that  the  tumor  is  hard  and  has  many  prolongations,  giving  the  idea  of 
"roots"  (Cooper),  to  which  the  laity  cling  so  tenaciousl}^  The  density 
is  due  to  the  relatively  large  amount  of  fibrous  tissue,  which  may  give 
the  impression  of  fibroma.  The  newl}^  formed  stroma  contracts  and 
draws   the  fibrous   septa   of  the  gland   from   all   directions   toward   the 


^  Palermo,  I  Tumori  della  Mammella  maschile,  Brangi,  Palermo,  1907. 


C.^KC/XfJ.MJ  ni    THE   HRK.IST 


410 


ptiipluiy  ot  rlu-  breast,  so  that  rlu-  niiiior  becomes  more  or  less  stellate 
oil  cross-section.  I  be  contractions  of  tbese  bands  produce  puckering 
of  the  skin  and  retraction  of  tbe  nipple  'Fig.  304).  In  some  instances 
tbe  tumor  begins  at  tbe  base  of  tbe  nipple  (Fig.  305).  Because  of  tbe 
close  assocKtrion  with  rlie  surrounding  connective  tissue  tbe  tumor 
is  immovable  within  the  gland,  but  since  the  septa  of  the  gland  are 
independent  ot  the  pectoral  fascia,  the  tumor  is  movable  over  the  chest. 
However,  when  the  growth  has  advanced  to  a  considerable  degree 
tbe  fascia  and  chest  wall  may  be  invaded  and  the  tumor  becomes  fixed. 
Occasionally,  though  rarely,  this  type  ulcerates  and  forms  fungous 
masses   ». big.   306). 

Fig.  306 


L  Icerating  scirrhous  carcinoma  of  the  mamma. 


Microscopically,  the  fibrous  element  predominates  markedly  (Fig. 
307),  and  large  areas  are  free  from  cells.  Prequentl\',  columns  of  cells 
are  seen  between  the  bands  of  fibrous  tissue.  The  fibrous  tissue  con- 
tains few  cells,  is  homogeneous,  and  frequently  is  defective  in  the  usual 
tinctorial  reaction  of  connective  tissue. 


420  TUMORS  OF  THE  MAMMARY  GLAND 

In  connection  with  the  scirrhus  may  be  mentioned  other  types  to 
which  special  terms  have  been  apphed,  the  varieties  depending  upon 
the  relative  amounts  of  stroma  and  parenchyma. 

Tumors  in  which  the  cells  are  present  in  greater  proportion  frequently 
become  attached  to  the  skm  at  a  number  of  points  simultaneously 
and  cause  a  reddening  over  a  considerable  area.  This  condition  was 
called  carcmomatous  dermatitis  by  the  older  writers. 

When  the  epithelial  elements  predominate  greatly  over  the  fibrous, 
the  carcinoma  is  called  medullary  or  encephaloid.  These  are  usually 
rapidly  growing  nodular  tumors  which  frequently  penetrate  the  skin 
and  form  fungoid  masses.  They  tend  to  early  metastasis.  Histologically 
they  are  composed  of  cells  with  very  little  connective  tissue. 


Fig.  307 


# 


^1 


Scirrhous  carcinoma  of  the  breast,  showing  small  cancer  nests  and  abundant 

connective  tissue. 

Midway  between  the  scirrhous  and  the  encephaloid  is  the  carcinoma 
simplex,  which  is  formed  of  cells  and  fibrous  tissue  in  about  equal  pro- 
portions. This  classification  is  unnecessary  because  it  marks  only  one 
pomt  in  the  gradual  variation  from  one  extreme  to  the  other. 

In  some  breast  carcmomias,  or  in  the  skin  after  an  attempted  extir- 
pation, many  small  nodules  develop  about  the  site  of  the  tumor  or 
extend  widely  over  the  chest.     These  are  called  carcinoma  en  cuirasse. 

Glandular. — In  this  variety  the  tumor  is  composed  of  rounded  lobu- 
lated  masses  (Fig.  308),  in  which  the  cellular  elements  predominate 
(Fig.  309).  They  are  less  dense  than  the  scirrhous  carcinomas,  but  the 
tumor  is  by  no  means  soft  and  has  a  distinct  "cancer  feel."  There  is 
no  retraction  of  the  nipple  (Fig.  310)  or  skin  because  the  stroma  keeps 
pace  with  the  cell  formation  and  produces  tension.     The  tumor  invades 


c.ikcixoM.i  oi  rill,  likii.tsr 


421 


rill  skill,  wliuh  hnuks  down  'I'lu.  31  i)  aiul  cxposts  tlic  fungous  mass 
to  inkction  ami  luriosis.  Tin-  incioial  lasiia  ma\  \n-  iiuailcd  iail\ 
t^i"  \'^\^v.  Mils  \aiui\  t  liioiinhout  Its  course  utains  tvidc-ncc  ot"  its 
glandular    stnictiiii',  Inn    m    some  areas    the    ;i,laiuliilai    anangc-meiit    is 

Fic;.  30S 


^ 


B«tis 
1^10 


Section  of  a  glaiulular  carcinoma  of  the  maninia. 


lost  and  the  structure  of  carcinoma  simplex  is  presented.  This  is  the 
type  of  carcinoma  which  develops  from  adenofibroma  and  from  senile 
mastitis.  Notwithstanding  the  large  size  of  these  tumors,  the)-  are 
less  malignant  than  the  scirrhous. 


422 


TUMORS  OF  THE  MAMMARY  GLAND 


Acute  Encephaloid  {Lactation  Cancers). — These  tumors  are  fortu- 
nately rare.  They  occur  in  young  women  and  frequently  come  on 
during  lactation,  though  they  are  by  no  means  confined  to  the  puerperal 


Fig.  309 


1?    ■*' 


0, 


'ft^     l* 


Glandular  carcinoma  of  the  breast. 


Fig.  310 


1 1510 


Fungating  glandular  carcinoma  of  the 
breast.  The  protuberant  nipple  is  shown 
at  the  upper  part  of  the  cut. 


State.  CHnically,  they  resemble 
an  acute  mastitis  (Volkmann),  and 
are  sometimes  mistaken  for  such. 
The  gland  enlarges  rapidly  and 
becomes  painful  both  spontane- 
ously and  on  pressure.  They  are 
usually  firm  with  a  superficial 
edema.  Early  metastasis,  particu- 
larly in  the  lungs,  is  the  rule,and  a 
fatal  termination  is  reached  within 
three  to  six  months.  On  section, 
they  are  homogeneous  and  pinkish 
white,  resembling  more  a  sarcoma 
than  a  carcinoma.  Microscopically, 
they  show  a  diffuse  infiltration  by 
the  glandular  epithelium  (Fig.  312). 
Facet's  Disease  of  the  Nipple. 
— In  i874Faget^  described  a  disease 


^  St.  Bartholomew's  Hosp.  Rep.,  x,  87. 


CARCINOM  I  OF   -/'///■:   liKI-.IST 


423 


ot  tlu'  ni|)plr  wliicli  IS  f  ittiiKiit  l\  l(>ll()\M(l  h\  c;in-iii()iii;i  ot  the  hicast. 
It  consists  111  ;in  cc/AiiKitous  inH;inHii;iti()n  about  tin-  nipi^U-  which  he 
compared  to  an  acute  hahinitis.  I  lie  surface  discharges  a  stick\-  \'iscid 
Huid,  which  may  dr\'  into  scales  and  crusts,  not  unlike  the  scales  in 
psoriasis.'  This  process  gradually  extends  beyond  the  nipple.  The 
skin  soon  becomes  thickened  and  hard.  Many  breasts  so  diseased  are 
subject  to  carcinoma,  which  is  most  often  of  the  scirrhous  type,  though 
other  types  have  been  observed.     I'he  older  opinion  was  that  the  initial 

Fig.  3 1 1 


Fungating  elandular  carcinoma  of  the  inainma. 


skin  lesion  was  an  eczema,  but  later  observers-  believe  that  the  carci- 
noma is  primary  and  that  the  skin  affection  is  the  secondary  process. 
The  argument  pro  and  con  may  be  summarized  as  follows:  In  favor 
of  the  primary  nature  of  the  skin  affection  may  be  mentioned:  (i) 
The  disease  ma}'  exist  man}'  years  before  a  carcinoma  can  be  demon- 
strated;   (2)    similar   lesions   are   found   on    the   penis,    scrotum,   vulva, 

^  Shields,  A  Clinical  Treatise  on  the  Diseases  of  the  Breast,  Macmillan,  London,  1898. 
-  Jacobaeus,  Virchow's  Arch.  f.  path.  Anat.,  1904,  clxxviii,  124;  Schambacher,  Deutsch. 
Ztschr.  f.  Chir.,  1905,  Ixxx,  332. 


424 


TUMORS  OF  THE  MAMMARY  GLAND 


and  umbilicus;!  (-^)  ^he  presence  of  peculiar  cells  in  the  epidermis;  (4) 
the  apparent  direct  continuation  of  the  epidermal  cells  into  the  carci- 
noma. In  opposition  to  the  primary  nature  of  the  affection  is:  (i)  The 
demonstration  of  early  involvement  of  the  cells  Hning  the  ducts  (Fig. 
313);  (2)  the  tumors  when  first  discovered  are  deep  and  may  retain  a 

Fig.  312 


's^K^'^y'  --—  ^  „4 


!$i'r'^ 


.  -"^§<« 


^'-vj':.-'-     :.       -%>. 'feists „'»-  °- __   ■    -    .    ^°'/y 


-s.-;-  f<=£'" 


0^^'i°~'?-° .'/,'/   =   «■     ■»      §_                    <>OOa,'»     '^'a     'j 

t'„"„>f'" 

Is^^f/""-,?;"  ".    °%sl-  e'^'^W"*' 

''V      - 

»»»."  '<--■•    .  »°,  "■»•  -"«o^"«  r                  '^  .*' 

«  °  • 

o^.#'^                              0   ^''^    ^           '  <"            „° 

*'  f.  t? 

^^^ 


^"-^     o'i- 


\^ 


Acute  encephaloid  carcinoma  of  the  mamma :    a,  milk  duct;  b,  cancer  nests;  c,  round- 
celled  infiltration;  d,  normal  lactating  breast. 

gland-like  structure;  (3)  pearls  are  never  formed  as  is  usual  in  skm 
carcinomas;  (4)  the  Paget's  cells  ma}^  result  from  metamorphosis  of 
epidermal  cells  from  the  more  deeply  lying  carcinoma;  (5)  eczema  of 
the  nipple  may  exist  without  the  development  of  the  carcinoma.     The 


^  Hannemiiller  and  Landois,  Beitr.  z.  klin.  Chir..  1908,  Ix,  296. 


C.lkCIXOM.I  or  TIIK  BREI^T  425 

interest  m  ilu-  lii.st()l()ii\  ot  xhv  ilisrasc  iHiitits  iihout  rlu-  so-calKcl  I\ifi;et  s 
ctlls.  I  lusr  il'ii;.  1I4)  inc  lar^f,  |Kilc-sr:iiniii}i,  cells  sunouiulccl  by  a 
sharp  honlri.       I  iuii-  sijiniHcancf  is  not  unclcTsto(Kl.    Jacobacus  believes 

Fig.  313 


'•     <    ■-.•>■  .'i'»i^**t'T'-i^'^        *-J\.'i'    •    ■■■■'         -  .'i^A 


■;.*ii  ,-*'.;-   ..  '     .  ■:  -  ....  ■;.-         ,-  ■.-.■.'.p  ^ 

,  •t*  ,  »2' ■■  ■■-'■■'      .      ■-  ■■■■-.--         .,   •     •• '.-v/      »<•'*  ••    ; 

V;      •••■•.-.■,:-.:•'       •  .'•    .  .■   •  ■     -■-       ,       ..  ,         •    .•  ■   -'••:•■»/''.■/'       ^/*',i    ,'^' 

rrolitVriirit)!!  of  rht-  tiiirhcliuni  in  the  lacriftmus  ducrs  in  Paget's  diseast  ot  rht-  nijiple. 

that  they  are  carcinoma  cells  derived  from  the  ducts  and  extending 
upward  into  the  epidermis,  and  this,  indeed,  seems  the  reasonable  expla- 
nation. The  chief  argument  against  the  ductal  origin  of  the  disease  is 
that  similar  processes  are  observed  elsewhere,  notably  about  the  scrotum. 

The    disease    usually    occurs 
in  women   beyond    middle   life  tic.  314 

who  are  married  or  have  borne  _,.^    -,  " 

children,    though   it    has    been  ^r^]&^   ^"    ■       ^^ 

seen  in  virgins  and  in  men.   It  v?  *^   -^^  \^      -'.?       %':^ 

is  essentially  a  chronic  process,  ;  '-  M  <->    ^    ^^     >    ^    >    '^ 

though  a  rapid  course  is  possi-  ^- \,  -^  --■='    ^^ '  ^  '^  ^  ^J'^'^'^ 

ble.       1  he    clinical    course    and  '^^    i?  s?  '^  ■  ^     ^>»  v'"?.» 


general     diagnostic     signs     are  ^V  V  --" /^->-   ff  ^'^^iP-S^i. 

those   of    ordinary    carcinoma.  ^'^ X-f^^'^  ItA^  ^i^^-    "^r^^ 

It  is  generally    admitted    that     (^^-■■.rA^--^-'^^^  S^ifh'      ^^     y.-^^^' 
there  is  a  true    eczema   ot   the  ^•v*^*'.*^  'o    ^  0^0 

nipple    which    is    not    raget  s 

disease  andwhich  isnot  followed  ^^^^.^^  ^^  ^^-^^  -^  p^g^^.^  ^-^^^^^  ^f  ^,^^  „i,,p,^^ 
b)-  carcinoma,  but   no  observa-  showing  (a)  the  so-called  Paget's  cells, 

tions  are   recorded  which   ma}' 

guide  to  a  differentiation  between  those  likeh'  to  be  followed  b}-  carci- 
noma and  those  which  are  not.  Chronic  disease  of  the  nipple,  there- 
fore, presenting  the  clinical  features  of  Paget's  disease  should  be  sub- 
jected to  microscopic  examination. 


426 


TUMORS  OF   THE  MAMMARY  GLAND 


Secondary  Degeneration. — Secondary  degenerative  changes  in  mammary 
carcinomas  are  not  frequent.  Colloid  degeneration  may  occur  in  the 
epithelium  or  in  the  connective  tissue  (Fig.  315).  The  tumor  is  then 
semisolid  and  the  cut  surface  is  jelly-like.  Areas,  particularly  about 
the  border,  retain  the  carcinomatous  structure.  Hemorrhage  occa- 
sionally takes  place  into  the  colloid  area  (Fig.  316)  and  may  cause 
rapid  enlargement  of  the  breast  and  lead  to  secondary  cyst  formation. 


Fig.  315 


Fig.  316 


^1 


Colloid  carcinoma  of  the  mamma.  Hemorrhage  into  a  colloid  cyst  of  the  mamma. 


Colloid  degeneration  is  especially  likely  to  take  place  in  metastases. 
Microscopically,  colloid  material  is  seen  within  or  surrounding  the 
cells.  These  changes  within  the  cells  are  believed  to  account  for  the 
relative  benignancy  of  these  tumors.  Fatty  degeneration  occurs  in 
mammary  carcinomas  and  is  manifest  macroscopically  by  small  canary 
yellow  areas,  and  microscopically  by  detritus  and  fat  globules  within 
the    meshes    of   connective    tissue.      Calcareous    infiltration    may    take 


i:,iR(:i\()M.i  oi  Tiir.  nRii.isr 


427 


placf  ill  siK-h  ureas  (  I'i^.  317).  CMosil)  assoclatici  \\\\\\  farr\  ckmiuia- 
rion  is  atioplu'.  I.ar^e  areas  of  Hlnous  tissue  are  seen  in  breast  carci- 
noma, and  it  has  Inen  assumed  that  the  epithehum  has  disappeared 
by  the  process  ol"  tatt\  defeneration.  Ihis  was  heheved  to  lessen  the 
rate  of  <i;ro\vth  ami  e\in  to  lead  to  spontaneous  cure  (Bryant).  Since 
tumors  have  been  subjected  to  more  careful  e\-aminatif)n,  such  cures 
have  become  strangely  rare. 

KiG.  317 


-i 


f  r 


fe.Bctfs 
J  i'3io 

Calcareous  degeneration  in  a  slowly  growing  glandular  carcinoma. 

Course  of  the  Disease. — The  greatest  variations  are  noted.  The  acute 
encephaloid  type  tends  to  run  its  course  in  a  few  months.  The  average 
case  of  other  types,  if  allowed  to  go  untreated,  tends  to  terminate  fatally 
in  from  three  to  five  years,  but  some  carcinomas  of  the  breast  show 
a  much  greater  chronicity.  Bryant^  reports  a  case  which  remained 
stationary  for  more  than  twenty  }-ears.  Spontaneous  cures  have  been 
reported.     The  correctness  of  the  diagnosis  in  such  instances  must  be 


1  The  Diseases  of  the  Breast,  Cassel  &  Co.,  London,  1887. 


428  TUMORS  OF  THE  MAMMARY  GLAND 

doubted.  Tumors  of  the  globular  fungous  type  would  seem  to  be  very 
malignant  3^et  the}^  grow  for  several  years  and  form  large  fungous  masses 
without  any  extensive  invasion  of  surrounding  parts.  Paget's  disease, 
originally  described  as  a  chronic  disease,  may  run  an  acute  course  as 
in  a  case  occurring  in  the  practice  of  J.  Block, ^  which  terminated  fatally 
in  less  than  six  months. 

Fig.  318 


mK 


■y^ 


Lymphatics  of  the  axillary  region. 

Dissemination.- — In  common  with  other  carcinomas,  dissemination 
occurs  chiefly  b}^  way  of  the  lymphatics.  The  lymphatics  of  the 
mamma  are  arranged  in  a  network  over  the  surface.  They  con- 
verge to  the  upper  and  outer  angle,  where  they  unite  into  several 
strands  extending  into  the  axilla  (Fig.  318).  Here  they  drain  into 
a  group  of  glands  which  lies  in  the  fatt}^  tissue  of  the  axillary  space. 

^  Personal  communication. 

^Oelsner,  Arch.  f.  klin.  Chir.,  1901,  Ixiv,  134. 


C.lkCIXOM.I  t)l     I  III'.    RRF.  IST  IlMI 

riu-Sf  II)  liiiii  stiul  out  (llcunt  \i-ssrls  wliicli  I  ci  iiiilKi  Ic  in  tlic  sii|)i;i- 
chi  \  uiil.i  1  ^l;lIuls,  ;ii)(l  llusc  toiiimimu;!  ( c  willi  llic  ihoiiKir  duct 
thr()U«j,li  hinph.itu-  \tssils.  ("IkiiuuIs  in;i\  p;iss  ilii(i-il\  lioin  the  maiii- 
iiui  I  \  Lil.iiul  It)  tilt  su|-)!  ;u-|;i\icul;i  I  l\  in  [ill  nodes.  I  lusc  simple  iinatomical 
consitlciat tolls  mtluMie  in  whuh  diietrion  \sc  iiuist  look  tof  rlic  earliest 
i\  itleiui  of  ilisseiiiinarioii.  Ilic  time  at  which  the  j^lands  become 
in\()l\  i-d  is,  ot  course,  variable,  and  is  often  as  early  in  the  scirrhous  as 
in  rile  cellular  tornis.  In  rlu-  latrer  ulciration  may  exist  for  \ears  with- 
out lilaiulular  involvement.  ()ccasionall\  ,  the  axiUai)'  glands  may 
escajH'  or  he  too  small  to  he  palpated  throuj:,h  the  intact  skin,  while  the 
suprachiN  iculai  <;laiuls  are  affected.  This  indicates  clearly  the  necessity 
of  examining  the  latter  <iroup  in  e\ery  case. 

The  frequenc\'  with  which  local  dissemination  takes  place  after  the 
removal  of  the  primary  tumor  has  long  led  surgeons  to  believe  that  local 
avenues  of  dissemination  were  more  numerous  than  is  usual  in  car- 
cinomas. This  is  perhaps  due  to  the  genetic  relationship  of  the  mam- 
mary gland  to  the  skin.  Handl\','  by  an  extended  series  of  studies, 
showed  that  there  are  numerous  lymphatics  between  the  skin  and  the 
iiiammar\-  gland.  These  studies  show,  as  clinical  experience  had  already 
abundantly  proved,  that  the  skin  in  the  region  of  the  gland  is  quite  as 
deserving  of  attention  in  planning  an  operation  as  are  the  regional  lymph 
glands. 

Visceral  metastasis  ma)'  occur  after  the  l^'mphatic  glands  are  involved 
or  ma\'  be  independent  of  them.  It  results  from  the  entrance  ot  cells 
into  the  blood  stream  directly  or  through  the  hmphatics.  When  general 
metastasis  has  followed  glandular  involvement  the  liver  is  more  likely 
to  be  affected,  but  when  dissemination  has  taken  place  through  the 
blood  stream,  the  lungs  seem  to  suffer  earliest.  The  latter  is  particu- 
larh'  likely  to  happen  in  the  acute  explosive  type.  Metastasis  in  bone 
has  not  received  the  attention  it  deserves.  It  occurs  most  frequently'  in 
or  about  the  neck  of  the  femur,  in  the  vertebrae,  and  in  the  humerus,  but 
any  region  may  be  attacked.  A  pathological  fracture  may  be  the  first 
evidence  of  the  disease.  So  frequent  are  bone  metastases  that  in  any 
fracture  from  apparently  insufficient  cause  the  breasts  always  should 
be  examined. 

Diagnosis. — When  most  of  the  mammar\'  tumors  reach  the  surgeon 
the  diagnosis  is  unfortunately  easy.  The  presence  in  a  middle-aged 
woman's  breast  of  a  hard,  non-capsulated  tumor  of  irregular  outline, 
with  dimpling  of  the  skin  and  retraction  of  the  nipple,  with  or  with- 
out lancinating  pains,  and  perhaps  with  enlargement  of  the  axillary 
glands,   makes  a   picture  so  typical   that  it  hardl\-  needs  discussion   as 

'  Cancer  of  the  Ikcast  and  its  Operative   ireatment,  John  Murra}-,  London,   1906. 


430  TUMORS  OF  THE  MAMMARY  GLAND 

to  diagnosis.  In  the  earlier  stages,  however,  the  diagnosis  may  be 
difficult,  and  it  is  then  necessary  to  take  into  account  all  of  the 
available  evidence.  The  necessity  for  the  exercise  of  any  diag- 
nostic acumen  seems  to  have  been  nicely  obviated  by  one  prominent 
surgeon  who  advised  that  in  any  doubtful  case  the  radical  operation 
should  be  performed.  This  advice  can  be  admitted  as  sound  only  when 
applied  by  those  who,  like  the  author  of  that  statement,  are  expert 
in  the  use  of  all  the  means  and  aids  to  diagnosis;  but  it  must  be  con- 
demned without  qualification  on  account  of  the  license  it  extends  to 
those  to  whom  the  nature  of  all  tumors  is  doubtful.  Those  who  have 
served  apprenticeships  in  the  laboratories  of  hospitals  will  admit,  and 
all  men  of  experience  know,  that  frequently  radical  operation  is  per- 
formed for  simple  lesions.  I  have  observed  this  in  cases  of  simple  fibro- 
adenomas, interstitial  mastitis,  and  simple  lobulation  in  a  developing 
breast.  Once  I  examined  a  pair  of  breasts,  removed  from  a  young 
woman  by  a  specialist  in  diseases  of  children,  and  to  this  day  I  have 
been  unable  to  find  any  excuse  whatever  for  their  removal.  The  doctor 
was  in  doubt. 

Most  of  the  conditions  which  are  mistaken  for  carcinoma  are  in  young 
women,  and  I  gladly  avail  myself  of  this  chance  to  second  Rodman  in 
his  emphasis  of  the  social  importance  of  preserving  the  mammae  of 
young  unmarried  women.  I  believe  it  is  a  greater  error  to  subject  a 
young  woman  with  a  simple  benign  lesion  to  a  radical  operation  than  it 
is  to  fail  to  extend  to  a  woman  the  20  per  cent,  chance  in  case  of  actual 
carcinoma.  Those  who  operate  when  they  strongly  suspect  malig- 
nant disease  must  be  able  to  offer  the  patient  every  known  means  of 
establishing  or  disproving  that  suspicion.  The  platitude  that  it  is 
better  to  sacrifice  a  dozen  suspected  breasts  rather  than  overlook  a  single 
case  of  carcinoma  has  long  served  as  a  cloak  for  ignorance  of  the  finer 
pathological  changes  in  the  gland.  It  is  unnecessary  and  unscientific  to 
subject  persons  with  an  innocent  disease  to  a  mutilating  operation,  and 
when  the  patient  is  an  unmarried  woman,  still  filled  with  the  universal 
hope  of  marriage  and  bearing  children,  the  error  of  performing  a  need- 
less radical  operation  is  not  less  than  overlooking  malignant  disease 
actually  present. 

The  clinical  evidence  presented  in  a  given  tumor  of  the  breast  is 
sufficient  to  warrant  an  accurate  diagnosis  in  the  vast  majority  of  cases. 
In  the  few  cases  m  which  doubt  exists  a  microscopic  examination  will 
clear  up  the  doubt.  There  is  no  need  to  deal  in  surmises  and  proba- 
bilities. 

History. — A  previous  inflammatory  affection,  the  presence  of  a  recent 
tumor,  and  the  age  of  the  patient  are  the  important  elements  to  be  noted 
in  the  history.      Injury,  as  has  been  frequently  pointed  out,  is    prob- 


c.ikcixoM  I  or  rill,  hreist 


4:u 


:ihl\  not  otttn  (.oniutrctl  uitli  tin  irioloj^y  of  rlu-  jiiowrh,  hut  serves 
larlui  ro  call  rlu-  arriiition  of  rlu-  patient  to  a  tumor  that  airead\' 
exists.  The  hisr()r\  of  the  case  is  of  greater  importance  in  forming 
the   prognosis   than   in   estahlishin^  the  cliajj;nosis. 


Fir,.  II q 


Kic.  320 


Pitting  of  the  skin  about  the  nipple  in 
carcinoma  of  the  mamma. 


Retraction  of  the  nipplein  carcinoma 
of  the  mamma. 


Fig.  321 


Deep  retraction  of  the  nipple  in  carcinoma  of  the  mamma. 

Inspection. — For  many  of  the  tumors,  inspection  estabhshes  the 
diagnosis.  The  most  valuable  evidence  to  be  gained  b^'  inspection  is 
the  retraction  of  the  nipple,  which  may  result  in  but  a  pitting  of  the 
skin  about  the  nipple  '  Fig.  319),  or  it  may  be  definitely  depressed  1  Fig. 
320),  or  even  almost  hidden  beneath  the  folds  of  surrounding  skin  (Fig. 


432  TUMORS  OF  THE  MAMMARY  GLAND 

321).  In  obscure  cases  valuable  service  has  been  given  by  the  sugges- 
tion of  Halsted^  that  over  the  seat  of  even  small  and  deeply  hidden 
tumors  the  skin  may  appear  to  be  drawn.  This  may  be  apparent  in 
some  positions  and  not  in  others.  This  sign  is  due  to  contraction  of 
the  septa,  which  later  causes  retraction  of  the  nipple  or  dimpling  of  the 
skin,  and  is,  therefore,  an  early  sign.  A  former  inflammation  may  pro- 
duce similar  conditions,  and  the  value  of  this  sign  is  therefore  lessened 
when  such  a  lesion  has  existed. 

Palpation. — The  chief  evidence  in  the  diagnosis  is  obtained  by  palpa- 
tion. If  the  breast  is  examined  in  the  usual  way,  that  is,  between  the 
thumb  and  fingers,  tumorous  masses  may  be  palpated,  especially  in 
young  women  and  in  breasts  undergoing  involution.  These  are  normal 
breast  acini.  The  proper  method  of  examining  the  breast  is  to  place 
the  hand  flat  upon  it.  The  normal  lobulations  are  not  felt  by  this  means, 
while  actual  tumors  are  felt  unless  veiy  small.  In  carcinoma  the  mass 
is  firm  and  does  not  move  readily,  since  it  has  no  capsule.  The  nipple 
frequentl}^  shows  retraction,  and  even  in  those  cases  where  retraction  is 
not  apparent,  the  nipple  cannot  be  lifted  up  between  the  thumb  and 
finger  as  in  the  normal  gland,  since  it  is  fixed  by  the  contracting  fibers. 
The  same  sign  may  be  elicited  better,  according  to  Halsted,  by  grasp- 
ing the  entire  breast  and  raising  it  up;  in  case  of  carcinoma  the  nipple 
remains  behind.  Dimpling  of  the  skin  occurs  when  the  tumor  approaches 
the  surface  at  regions  other  than  at  the  nipple,  and  may  be  demon- 
strated in  the  same  way.  The  axillary  glands  may  be  enlarged  and 
present  the  dense  bean-like  feeling  characteristic  of  carcinomatous 
glands.  In  the  fungoid  type  the  entire  breast  itself  forms  a  dense  mass 
and  the  tumor  may  be  necrotic  and  foul  smelling.  In  the  acute  explo- 
sive type  there  is  a  very  rapid  development,  with  reddening  of  the 
surface.     The  entire  mass  is  hard  and  non-elastic  and  but  little  tender. 

Differential  Diagnosis. — Fibro-adenomas  usually  occur  in  young 
women,  are  distinctly  encapsulated,  move  freely  on  palpation,  and 
the  lymphatic  glands  are  not  involved.  They  are  often  multiple,  and 
frequently  bilateral.     They  are  painful,  particularly  in  neurotic  girls. 

Mastitis. — Interstitial  mastitis  occurs  in  unmarried  women,  and 
nearly  always  in  those  who  have  menstrual  disturbances.  The  entire 
breast  is  more  or  less  involved  and  presents  an  indurated  mass  con- 
taining cysts  of  varying  size,  which  are,  however,  usually  too  tensely 
filled  and  too  small  to  give  fluctuation.  There  is  usually  spontaneous 
pain  and  always  tenderness  on  pressure.  The  pains  are  localized  and 
burning,  not  lancinating  as  in  carcinoma.  The  tumor  is  flat  and  diff'use 
and  maintains  in  a  general  way  the  form  of  the  breast.     It  is  not  at 

1  Ann.  Surg.,  1907,  xlvi,  i. 


(:,fk(:/\o\/./  or  nil:  ukh.isr  433 

aii\'  stajif  hxid  lo  tlu-  iiiulci  l\  iii<;  hiscKi.  It  ma\  exist  tor  main'  \'ears 
With  IK)  t(iuKiu\    to  lapul  tiilar^iimni . 

Chronic  miiiK-  mastitis  usualh  oteins  at  tlic  a|)|)r(jacli  of  the  meno- 
pause. I  lie  ;i,Ian(l  [iresents  a  nodular  mass  \sIikIi  is  unlike  the  sinj:;le 
iiiemilai  mass  ol  tin-  scirrhous  eaiu-er.  In  chronic-  masnris  there  is 
not  the  distinct  encapsulation  of  the  hhro-adenoma  nor  the  fixation 
of  scinhus.  it  does  not  form  a  pronunent,  rapidly  ^rowiiif:;  tumor 
liki-  the  notliilar  carcinomas.  \\  hen  areas  of  senile  mastitis  become 
more  dense  and  more  fixetl  than  is  common,  a  malignant  transformatif)n 
may  be  suspected. 

MiXKD  Tumors. — Mixed  tumors  are  encapsulated  and  are  at  first  of" 
slow,  later  of  rapid,  <i;ro\vth,  and  even  when  they  attain  considerable 
size  do  not  tend  to  ulcerate,  and  the  glands  are  not  involved.  rhe\' 
vary  in  consistency,  but  are  usually  soft  and  semifluctuating. 

Tuberculosis,  Syphilis,  and  Actinomycosis. — Early  tuberculous  in- 
flammation or  the  conglomerated  variety  of  tuberculosis  may  simulate 
carcinoma.  The  lymph  glands  are  often  involved  in  the  process,  but 
the}'  are  large  and  soft  and  not  small  and  dense  as  in  carcinoma.  The 
disease  usually  affects  young  persons  and  those  who  are  subject  to 
tuberculosis  in  other  parts.  When  a  sinus  has  formed,  the  crateriform, 
undermined  opening  and  the  thin  purulent  discbarge  are  characteristic. 
In  the  conglomerate  variety  a  section  may  be  necessary  to  establish 
the  diagnosis  with  certainty.  Syphilis  of  the  gland  is  a  vet}'  rare  affec- 
tion and  usually  disappears  under  treatment  with  potassium  iodide. 
Actinomj'cosis  may  form  an  indurated  mass  which,  however,  resembles 
tuberculosis  more  than  carcinoma.  The  sinus  formation  and  the  dis- 
charge  of  the  canary  yellow  bodies  are  characteristic. 

Inflammation. — In  rare  instances  an  inflammation  of  the  breast  may 
closely  simulate  lactation  carcmoma.^  Spifne  weeks  after  childbirth 
one  or  both  breasts  swell  and  become  painful.  The  vessels  become 
turgescent,  and  there  is  often  slight  elevation  of  temperature.  The 
breast  is  dense  and  firm,  simulating  carcinoma  closely,  but  the  skin 
remains  movable  over  the  enlargement.  On  section,  they  are  a  homo- 
geneous pinkish  white,  with  islands  of  cells  closely  resembling  cancer 
nests.  Histologicalh',  the  cells  of  the  ducts  are  piled  up  and  are  not 
functionating.  Function  has  given  place  to  growth,  but  the  cells  are 
confined  within  the  basement  membrane. 

Prophylaxis. — The  prophylaxis  of  mammary  carcinoma  is  neces- 
sarih'  limited,  yet  there  are  certain  conditions  associated  with  the 
occurrence  of  carcinoma  of  the  breast  which  are  to  be  observed  with 
a  certain  degree  of  suspicion. 

^  Chaput  et  Souligoux,  Bull,  et  mem.  soc.  de  Chir.  de  Paris,  1906,  xxxii,  953. 
28 


434 


TUMORS  OF   THE  MAMMARY  GLAND 


Mastitis. — Ten  per  cent,  of  breast  carcinomas  are  preceded  b}' 
mastitis.  It  would  seem  that  a  woman  who  had  such  an  inflamma- 
tion should  be  mformed  of  this  association  and  cautioned  to  seek  advice 
if  in  after  life  any  change  appears  in  the  affected  breast.  The  percentage 
of  carcinomatous  breasts  which  have  previously  been  the  seat  of  inflam- 
mation can  be  approximated,  but  it  is  impossible  to  estimate  the  per- 
centage of  breast  inflammations  which  have  afterward  become  malignant. 
The  danger  of  causing  mental  distress  b}"  such  suggestion  should  not 
be  very  great. 

Fig.  322 


Edema  of  the  arm  from   metastatic  mammary  carcinoma  of  the  axilla. 

Involution  Changes. — Our  knowledge  of  the  finer  changes  incident 
to  involution  is  as  yet  incomplete.  Bloodgood  has  made  valuable 
studies  in  this  particular.  A  gland  which  has  enlarged  or  causes  pain 
at  or  near  the  menopause,  even  when  no  definite  tumor  can  be  dis- 
covered, should  be  regarded  with  suspicion.  If  an  actual  tumor  is 
present,  it  should  be  subjected  to  local  excision. 

Benign  Tumors. — After  carcinomas,  the  adenofibromas  are  the 
most  frequent  type  of  tumor.  Much  discussion  has  arisen  as  to  the 
proportion  of  these  tumors  which  afterward  become  malignant.  The 
percentage  is  very  small,  but  the  change  occurs  probabh'  more  fre- 
quently in  those  in  which   the  glandular  element  is  especially  promi- 


c./Rc/xoM.i  or  THE  hri-.ist  4:1.') 

luiit.  I  lull  rrni()\;il  is  such  ;i  simple-  matici  tli;it  ir  mi:i\  Ik-  ;i(l\ise(l 
in  t'\(.-!\  ciisi-,  and  in  in  il  it  ilots  no  otliii  j^ood,  it  will  |)rf\c-nr  sonu- 
incxpfiit-nctii  opiiafoi  lioin  doin^,  a  ladical  ()|)iiari()n  iindii  rhc  diag- 
nosis ot  cat  CI  noma. 

Treatment.  I  lu-  distasc-  is  no  l<)n<;ti  ciiiablc-  when  tin-  rumor  is 
adlurtiu  to  rlu'  pectoral  fascia,  w  lun  inulri|-)lc-  nodules  exist  in  the 
skni,  when  the  supracla\icular  glaiuls  ait-  (.xtensixely  involved,  when 
there  is  edema  of  the  arm  from  axillar\  invasion  (Kig.  322),  and,  of 
course,  wlun  tlure  are  osseous  or  \isceial  metastases.  Operations 
undertaken  under  these  conditions  are  but  palliative.  Operati\c  re- 
moval is  the  only  treatment  to  be  considered  when  the  diagnosis  of 
carcinoma  is  established.  In  no  other  operation  is  the  techni(jue 
employed  so  universally  accepted,  though  there  are  slight  variations 
depending  on  the  notions  of  various  surgeons  as  to  the  regions  where 
recurrence  is  most  likely  to  take  place.  Most  operators  advise  \er\' 
radical  measures,  namely',  the  remoxal  of  a  large  area  of  skin,  the  entire 
gland-bearing  area,  and  the  pectoral  muscle  in  early  cases,  that  is, 
when  there  is  no  axillary'  gland  involvement;'  but  all  are  agreed  that 
a  large  number  of  recurrences  take  place  in  the  glands.-  There  is  no  evi- 
dence of  recurrence  in  the  muscles.  Greenough's  statistics  show  even 
better  results  where  the  pectoralis  major  is  not  removed.  He  explains 
this  by  the  statement  that  more  advanced  cases  are  now  operated 
upon  than  when  the  statistics  covering  operations  without  removal  of 
the  pectoralis  were  obtained. 

As  a  summary  it  may  be  stated  that  the  testimouA-  is  in  accord  in 
demanding  the  removal  of  a  large  area  of  skin.  The  evidence  in  favor 
of  the  removal  of  the  pectoral  muscles  is  not  ver\'  great;  the  chief  argu- 
ment in  favor  of  this  procedure  is  that  the  removal  of  the  glands  is 
facilitated  therebw  The  operative  mortality  is  not  appreciably  greater, 
but  the  disability  of  the  arm  is  more  pronounced.  Carcinoma  nowhere 
shows  any  disposition  to  form  secondar}-  deposits  in  voluntar\-  muscle 
except  by  direct  extension.  It  is  my  belief,  therefore,  that  it  is  safe 
to  leave  this  muscle,  even  though  the  removal  of  the  glands  ma\'  be 
more  difficult.  An  area  of  skin  as  large  as  the  mamma  should  ordinarilv 
be  removed.  Henderson^  recommends  the  removal  of  the  "exposed" 
portion  of  the  serratus  magnus  muscle  when  the  tumor  lies  above  it. 

No  set  plan  of  operation  is  practised  by  most  surgeons.  It  is  in 
harmony  with  the  general  principles  of  the  operative  surger\'  of  carci- 
noma to  begin  at  the  origin  of  the  most  distal  hniph  glands  and  proceed 

'  \'andtT  \'eer,  Surg.,  Gynec,  and  Obstet.,  igo/,  v,  33. 

-  Greenough,  Ann.  Surg.,  1907,  xlvi,  20,  and  Surg.,  Gynec,  and  Obstet.,  1907,  v,  39. 

^  Brit.  Med.  Jour.,  1909,  ii,  1221. 


436  TUMORS  OF  THE  MAMMARY  GLAND 

toward  the  tumor;  thus,  in  case  of  mammary  cancer  to  begm  at  the 
clavicle  and  work  toward  the  gland  seems  to  be  the  most  rational  pro- 
cedure. 

In  general,  the  plan  of  Willy  Meyer^  may  be  followed.  An  incision 
is  made  parallel  to  the  clavicle,  exposing  the  vessels  which  supply  the 
mammar}^  area.  By  controlling  the  vessels  here  the  entire  region  of 
the  gland  is  made  to  some  degree  ischemic.  The  axilla  is  exposed  by 
the  same  incision,  and  the  dissection  then  extends  to  the  breast.  The 
removal  of  the  breast  last  is  said  to  protect  the  chest  from  exposure 
to  cold  during  the  operation,  and  it  certainl}^  protects  the  wound  from 
infection  by  carcinoma  cells.  The  selection  of  the  skin  incision  can  be 
left  to  suggest  itself  to  the  operator  at  the  time  of  operation.  In  this 
way  there  is  more  likelihood  of  suiting  the  incision  to  the  disease  than 
in  making  some  set  incision,  the  chief  merit  of  which  is  to  make  a  wound 
which  will  be  easy  to  close.  Numerous  plastic  incisions  have  been 
recommended,  the  best  of  which  is  that  of  Jackson,-  which  ma}^  often 
be  used  to  advantage. 

Paget's  disease  should  be  treated  by  excision  as  soon  as  encountered. 
If  there  is  a  precarcinomatous  period,  inspection  during  the  course 
of  the  operation  will  establish  the  fact.  If  carcinoma  is  already  present 
the  same  treatment  should  be  followed  as  in  any  other  breast  carcinoma. 

Complications  after  Operation. — Edema  of  the  arm  from  compression 
of  the  veins  by  the  scars  or  elephantiasis  due  to  a  destruction  of  the 
lymphatics  occurs  in  about  lo  per  cent,  of  the  well-operated  cases. 
The  thickening  of  the  arm  in  many  cases  reaches  such  a  degree  as  to 
incapacitate  the  patient.  Careful  search  is  often  necessary  before  it 
is  possible  to  decide  whether  the  obstruction  is  due  to  the  scar  or  to 
recurrence  of  the  tumor.  There  is  no  relief  from  the  condition,  though 
vascular  anastomosis  may  offer  some  hope  in  the  future.  Attempted 
angioplasty,  so  called,  by  burying  a  silk  cord,  has  little  to  commend  it 
in  principle  and  it  gives  but  little  hope  in  practice. 

Limitation  of  movement  of  the  arm  by  scar  is  not  remediable  by 
operation.  The  presence  or  absence  of  the  pectoral  muscles  and  the 
amount  of  scar  tissue  in  the  axilla  have  some  influence  on  the  mobility. 
Clean  operating  and  careful  coaptation  of  tissue  is  the  best  safeguard. 

Operation  of  Recurrences. — Skin  recurrences  may  be  operated  on  with 
advantage  frequently.  Nodules  in  the  scar  may  be  removed  with 
some  prospect  of  a  further  period  of  relief.  When  the  recurrences  appear 
in  crops  about  the  scar,  or  when  they  occur  in  other  parts  of  the  body, 
further  operative  attempts  are  useless. 

1  Med.  Rec,  New  York,  1894,  xlvi,  746. 
-Jour.  Amer.  Med.  Assoc,  1910,  liv,  178. 


cjRCiso.M.i  or  THE  hkk  isr  a'M 

Results  of  Operation.  I  In  results  ot  ope  rati  vc  rnaniienr  reporrtcl 
l\\  luiiiieious  operators  give  a  fairly  unitorni  result,  aiui  may  be  placed 
as  25  per  cent,  of  cures.  Statistics  to  l:)e  of  use  must  state  the  type  of" 
tumor  present,  the  extent  of  the  disease,  and  the  type  of  operation 
pertoi  nucl.  \\  irli  rhisi-  factors  known,  an  operatixe  prognosis  nia\  he 
given  \Mth  a  general  degree  of  accuracw  I  he  proportion  of  cures 
accorduig  to  the  types  of  tumors,  as  stated  b\"  Cjreenough,  is  as  follows: 
Medullary,  16  per  cent.;  scirrhous,  23  per  cent.;  adenocarcinoma,  47.6 
per  cent.;  Paget's  cancer,  12.5  per  cent.;  carcinoma  of  the  lactating 
breast,  2S  per  cent.  These  results  correspond  in  a  general  way  with 
Halsted's  statistics,  and  tend  to  show  that  the  adenocarcinoma,  in 
which  Halsted  had  j ^  per  cent,  cures,  give  the  best  prognosis,  while 
the  medullar)'  and  scirrhous  carcinomas  give  a  relatively  poor  prognosis. 
The  number  of  Paget's  disease  and  lactating  breast  carcinoma  reported 
are  too  small  to  be  of  value  statistically.  Taking  the  reported  cases 
as  a  whole,  the  prognosis  is  better  as  relates  to  Paget's  and  worse  for 
the  lactating  carcinoma  than  is  indicated  by  Greenough's  statistics. 

Of  even  more  importance  than  the  t\pe  of  the  disease  is  the  extent 
of  the  disease  at  the  time  of  operation.  As  the  lymph-gland  in\'ol\e- 
ment  increases,  the  prognosis  becomes  rapidly  worse.  This  is  the  most 
important  point  in  determining  the  prognosis. 

\\  hen  the  supraclavicular  glands  are  involved  the  prognosis  is  bad. 
Halsted  obtained  7  per  cent,  cures,  while  Greenough's  statistics  contain 
no  cures.  Likewise,  when  the  second  breast  is  involved,  Greenough 
reports  no  cures,  w^hile  Halsted  reports  cures  seven  and  one-half  and  five 
and  one-half  years  after  operation  on  the  second  breast.  When  the 
axillary  glands  alone  are  involved,  the  prognosis  stands  about  midway; 
when  the  lower  glands  alone  are  involved,  the  prognosis  is  but  little 
worse  than  when  they  are  not  involved;  while  when  the\'  are  extensivel}' 
diseased,  the  prognosis  is  nearh'  as  bad  as  when  the  supraclavicular 
glands  are  involved.  This  is  at  once  clear,  for  it  has  been  shown  that 
the  supraclavicular  glands  are  involved  in  the  most  of  these  cases,  though 
they  may  not  be  palpable  until  the  fascia  is  incised,  as  has  been  shown 
by  Pilcher. 

The  t\pe  of  operation  has  less  influence  on  the  prognosis  than  is  gen- 
erally supposed.  Greenough  tabulates  his  cases  according  to  the  thor- 
oughness of  the  operation.  Under  the  complete  operation  the  pectoralis 
minor,  the  sternal  portion  of  the  pectoralis  major  with  the  axillar\'  con- 
tents, together  with  a  generous  area  of  skin,  are  removed.  That  the  skin 
removed  was  considerable  is  attested  b\'  the  fact  that  in  160  operations 
67  required  skin  grafting.  In  this  series  but  16  per  cent,  remained  free 
from  the  disease.  In  the  semicomplete,  in  which  the  operation  was  the 
same  as  in  the  first  group,  except  that   the  muscles  were  not  removed. 


438  TUMORS  OF  THE  MAMMARY  GLAND 

25.3  per  cent,  of  cures  resulted.  In  the  incomplete,  in  which  sometimes 
a  part  of  the  breast  and  some  of  the  axillary  contents  were  allowed 
to  remain,  25.9  per  cent,  of  cures  resulted.  The  explanation  for  these 
results  is  given  by  the  fact  that  more  advanced  cases  were  operated 
by  the  more  radical  method.  However,  other  statistics  give  the  same 
results. 

There  is  a  lack  of  statistical  evidence  to  show  that  the  removal  of 
the  pectoral  muscles  improved  the  prognosis  materially.  Indeed, 
many  operators  regard  their  removal  as  of  importance  only  in  giving 
freer  access  to  the  axilla.  The  importance  of  the  removal  of  a  sufficiently 
extensive  area  of  skin  should  receive  the  greatest  emphasis,  for  more 
than  50  per  cent,  of  recurrences  are  in  the  skin.  Tension  on  the  skin 
in  closing  the  wound  increases  the  likelihood  of  recurrence.  In  Green- 
ough's  statistics  57.6  per  cent,  remained  free  when  grafts  were  used, 
while  but  44  per  cent,  remained  free  when  the  edges  were  drawn 
together.  The  statistics  of  foreign  operators  correspond  closely  with 
those  of  American  surgeons,  though  on  the  whole  their  results  are  not 
so  good;  improvement  was  noted,  however,  when  the  extensive  skin 
removal  according  to  Halsted's  method  was  employed. 

It  is  generally  recognized  that  recurrences  after  the  three-year  limit 
are  frequent.  Thus  Ransohoff^  reports  37  cases  in  which  recurrence 
took  place  after  six  3^ears,  and  i  case  in  which  recurrence  occurred 
after  twenty-one  years.  In  Greenough's  statistics,  19  per  cent,  of 
those  which  passed  the  three-year  limit  showed  recurrence  later. 

1  Ann.  Surg.,  1907,  xlvi,  72. 


C  II  A  V'\    \:  k     X  X  X   I 


TUMORS  ()!•    I  IIK  AUDOMINAI.  WALL  AM)  LMIULKIS 

TUMORS    OF   THE    ABDOMINAL   WALL 

Lipomas.  Lipomas  arc  tlu-  most  fieeiiRiU  tiiinois  oF  the  ahdoniinal 
wall,  anil  are  usiiall)  found  on  tin-  sides.  They  differ  in  no  way  from 
lipomas  in  other  rejiions,  either  in  diagnosis  or  treatment.  One  excep- 
tion, however,  to  this  general  rule  needs  to  he  mentioned.  In  the  hnea 
alha  small  lipomas  appear  which  have  elongated  pedicles  connected 
with  the  peritoneal  fat,  frequently  at  long  distances  from  the  site  of 
the  tumor  (Fig.  323).  It  is,  therefore,  necessary  in  attacking  these 
tumors  to  observe  all  the  technical  precautions 
required  for  laparotomy.  They  are  frequently- 
associated  with  digestive  disturbances  and  are 
virtualh-  properitoneal  hernias  and  require  the 
treatment  usually  accorded  hernias. 

Keloids.  The  abdomen  and  chest  form  the 
most  common  site  of  keloids,  particularly  those 
of  the  massive  type  (Fig.  324).  They  form 
superficial  nodulated  sessile  masses  which  cause 
disturbance  from  their  size  alone. 

Carcinomas.  —  These  are  not  infrequenth' 
located  on  the  abdominal  wall,  sometimes  in 
the  flanks.  They  form  ulcers  which  have  the 
usual  dense  borders  characteristic  of  carcinomas. 

Syphilitic  ulcers,  especially  when  about  the  pubes,  are  sometimes  mis- 
taken for  carcinomas.  The  treatment  of  carcinoma  is  the  same  in  this 
region  as  elsewhere.  It  is  often  difficult  to  anticipate  the  direction  of 
the  metastasis,  because  the  lymphatics  radiate  in  all  directions. 

Desmoids. — This  term  is  pureh"  a  clinical  one,  which  is  applied  to 
dense  fibroid  tumors  in  the  abdominal  wall.  These  are  quite  definite 
in  both  patholog\-  and  incidence;  they  stand  midwa\'  between  the  sar- 
comas and  Hbromas,  and  occur  most  frequenth"  b\-  far  in  women  between 
twenty  and  thirty-five  >-ears  who  have  borne  children.  Ihey  have 
been  observed  in  the  imparous  and  in  men.  In  a  considerable  percentage 
of  cases  the\'  are  first  observed  during  pregnancy,  and  when  the}'  exist 
before  pregnane}-  often  take  on  rapid  growth  during  that  period.     The 


If'O 


Lipoma  of  abdominal 
wall. 


440 


TUMORS  OF  THE  ABDOMINAL  WALL  AND  UMBILICUS 


reason  for  this  association  is  not  understood.  They  occur  most  fre- 
quently on  the  posterior  layer  of  the  rectus  sheath  above  the  umbilicus 
(Fig.  325)  (Olshausen),  or  in  the  flank  below  the  umbilicus  (Pfeiffer). 
They  are  sometimes  observed  in  the  lateral  abdominal  walls  intimately 
attached  to  the  costal  cartilages  or  the  crest  of  the  ilium.  Rupture 
of  the  rectus  during  labor  has  been  suggested  as  causative,  a  sugges- 

FiG.  324 


Keloid,  widely  distributed. 

tion  strengthened  by  the  fact  that  ruptures  of  the  rectus  usually  take 
place  in  the  posterior  surface  of  the  muscle.  Against  this  is  advanced 
the  argument  that  the  tumors  do  not  go  out  from  the  muscle,  but  from 
the  fascia.  Desmoids  which  are  attached  to  the  bone  and  cartilage 
likewise  apparently  go  out  from  the  fascia. ^ 

1  Olshausen,  Ztschr.  f.  Geburtsh.  u.  Gynak.,  1899,  xli,  271. 


TiMoks  or  nil-:   ihdomix  ii.  ii .//./. 

Kic.  325 


441 


Desmoid  of  the  posterior  sheath  of  the  rectus. 
Fig.  326 


Desmoid  of  the  posterior  sheath  of  the  rectus. 


442  TUMORS  OF  THE  ABDOMINAL  WALL  AND  UMBILICUS 

Macroscopic  Appearance. — The}'  appear  usually  as  a  flattened  ovoid 
(Fig.  326),  and  when  large  are  often  spherical,  but  they  may  be  disk- 
shaped.  Thev  vary  in  size  from  a  hazelnut  to  masses  weighing  twenty 
pounds  or  more.  Their  encapsulation  is  not  perfect,  and  there  is  more 
or  less  attachment  to  the  surrounding  tissue  without  there  being  definite 
infiltration.  On  section,  they  are  white  or  pinkish  white,  and  some- 
times fibrous  bands  can  be  made  out.  Calcareous  infiltration  and, 
in  the  large  ones,  myxoid  degeneration  have  been  noted. 

Microscopic  Appearance. — The  finer  structure  is  that  of  a  cellular 
fibroma  (Fig.  327J.  The  cells  vary  greatly  in  number  and  size;  in  some 
cases  they  have  been  so  large  and  numerous  as  to  warrant  the  diag- 


Desmoid  of  external  oblique  muscle,  cellular  type,  showing  spindle  cells  cut  both 
transversely  and  longitudinally. 

nosis  sarcoma,  though  the  clinical  behavior  does  not  always  correspond 
to  the  cellular  content.  The  border  of  a  desmoid  often  shows  a  slight 
tendency  to  infiltration,  so  that  muscle  fibers  become  included  in  the 
developing  fibrous  tissue  (Fig.  328),  in  which  respect  as  well  as  in  some 
others  it  resembles  myositis  fibrosa. 

Clinical  Course. — The  clinical  course  and  symptomatology  are  sub- 
ject to  slight  variations.  Usually  the  inconvenience  they  cause  results 
purely  from  size,  though  sometimes  they  are  painful.  The  rate  of  growth 
is  usually  slow,  though  sometimes  it  becomes  rapid,  particularly  in 
tumors  containing  myxoid  elements.  In  their  growth  the  surrounding 
muscle  may  disappear,  which  accounts  for  the  striking  fact  that  not- 


rr.MfjRs  or  riii:  .ihdomiwii.  ii  ill  443 

u  irli.st;iiuliiiL:,  tluii  mtmiati-  ;issi)ii;i  t  nm  with  the  posrciioi  slu-;irhs  rlu- 
luilk  ot  ilu-  tiinioi  |)i<)|r*.ts  ()iit\\;iicl.  I  Ih\  m;i\  when  lar^c,  howcN'er, 
|>r()|ci.t  iiiio  till-  ;iI>i1()I1iim:i1  cwNitv  ;iiul  ohtiuii  srtoiulary  artiKlinu-nts.' 
Diagnosis.  I  luii  t];ir  oNoid  sluipi-  in  liiu-  of  tin-  ii-crus  iisu;ill\  makes 
it  possihk-  to  iic()i:m/c-  rluiii  at  a  <i,lanc(.-.  I*al|>ati()n  wluii  the  tumor 
is  Hxt'cl  In  coin  I  action  ot  the-  muscle  makes  it  douhlv  sine,  but  wlien 
tlu'  ahclommal  wall  is  c\tensi\ely  displaced  the-  muscle  test  is  of  little 
a\ail.  \\  In  n  siruatctl  lulovv  and  lateral  to  rlu-  und")ilicus,  they  have 
heiii  misrak(,n  tof  rumors  arising  from  rlu-  |kI\ic  organs,  and  wlu-n 
aho\r  rlu'  umhilicus,  wirh  ck-nse  rumors  of  rlu-  upper  abdominal  organs, 

V\r..  328 


Desmoid  of  shearh  of  rectus  muscle,  showing  inclusion  of  muscle. 

notabl\-  carcinomas  of  the  stomach,  gall-bladder,  mesentery,  and 
omentum.  When  such  problems  arise  diagnosis  by  exclusion  must  be 
attempted.  Hematomas  and  inflammatory  lesions  can  be  ruled  out 
by   the  histor}'. 

Prognosis. — When  removed  there  is  little  tendency  to  recur,  but  recur- 
rences have  been  reported,-  and  a  tumor  may  appear  in  a  different 
region;  in  such  instances  rapid  spreading  in  the  abdominal  wall  may 
take  place.  Stone^  states  that  statistics  show  recurrences  in  90  per 
cent,  of  women  and  68.1  per  cent,  of  men,  while  Pfeiffer*  gives  but 
21.3  per  cent,  recurrences  in  women. 

'  A.  I.  Bouffleur.  Ann.  Surg.,  i8gQ,  xxx,  587. 

-  Hanks,  Amer.  Jour.  Obstet.,  1883,  xvi,  284.  ^  Ann.    Surg.,  1908,  xlviii,  175. 

*  Beitr.  z.  klin.  Cliir.,  1904,  xliv,  334. 


444 


TUMORS  OF  THE  ABDOMINAL  WALL  AND  UMBILICUS 


Treatment. — Excision  without  opening  the  peritoneum  should  be 
attempted.  When  small  the  opening  in  the  fascia  is  easily  accom- 
plished, but  when  large,  difficult}^  may  be  experienced  not  only  because 
of  possible  complications  from  secondary  attachments,  but  also  be- 
cause of  the  difficulty  of  closing  the  large  wounds  resulting  from  their 
removal. 

Sarcomas. — Tumors  which  have  the  external  form  of  desmoids 
sometimes  have  the  histology  of  fibrosarcomas,  though  presenting  the 
clinical  characters  of  endotheliomas.  They  may  remain  dormant 
for  many  years,  then  suddenly  enlarge  in  response  to  some  stimulus. 
They  have  in  their  clinical  course  much  in  common  with  the  desmoids, 

Fig.  329 


Secondary  sarcoma  of  the  abdominal  wall  after  sarcoma  of  the  ovary. 


but  they  are  subcutaneous.  Another  and  more  common  type  is  globular 
and  projects  from  a  sessile  base  on  the  surface  of  the  abdomen.  The 
skin  covering  the  summit  is  thin,  red,  and  resembles  mucous  membrane 
more  than  it  does  the  surrounding  skin.  They  usually  develop  slowh" 
for  many  years,  but  in  response  to  trauma  or  from  an  unknown  cause 
they  may  develop  rapidly  and  invade  the  surrounding  tissue.  In  some 
instances  the  tumor  is  quite  free  from  its  capsule,  and  when  the  thinned 
skin  becomes  destroyed  the  tumor  mass  may  become  extruded.  In  some 
of  these  tumors  the  structure  of  endotheHomas  is  closely  imitated.  Their 
clinical  course  resembles  the  endotheliomas  more  than  the  sarcomas. 
Excision  has  resulted  in  a  cure  in  the  cases  coming  under  my  observa- 
tion. 


riMoRs  or  Tin:  iw/n/L/cus  m:, 

Recurrent  Tumors.  Not  iiilV((|ii(iiil\  ,  atur  opiiarion  toi  m;ili^- 
iKiiu  (list-asc,  icciUTc-iu-c's  appear  aloii^^  the  liiu-  of  iiuision.  I  his  is 
most  apt  to  occur  after  wvy  iiialifi,naiit  sarcomas  of  tlie  uterus  and 
ovaries,  hut  ma\  h»llo\\  less  mah^uaiit  tumors  and  even  c\'stadenomas 
ot  the  o\ar\,  not  ri'^arded  as  maH<inant.  Isually,  irregularly  nodulated 
masses  (  Kig.  ;,2(;)  leplace  the  scar  and  ma\    ulcerate. 


TUMORS    OF   THE    UMBILICUS 

I  he  umhihcus  is  rarel\  the  seat  of  tumors,  but  developmental,  pri- 
mary, and  secondary  tumors  have  been  observed. 

Carcinoma. — Primary  malignant  epithelial  tumors  are  exceedingly 
rare,  'l^he  squamous-celled  type  does  not  differ  from  skin  carcinomas 
elsewhere,  and,  despite  the  irritation  to  which  the  umbilicus  is  sub- 
jected, seems  to  be  more  rare  here  than  in  other  regions  of  the  epidermis 
of  the  abdominal  wall.  The  adenomatous  type  is  likely  to  be  confused 
with  metastatic  tumors;  in  fact,  only  one  certain  example  has  been 
reported. 1  Secondary  carcinomas  kre  more  common,  Cullen-  having 
recently  reported  three  cases.  They  are  usually  secondary-  to  primary 
carcinomas  of  the  stomach,  gall-bladder,  or  intestine.  They  appear  as 
hard,  circumscribed  tumors,  and  are  often  observed  before  evidence 
ot  a  pnmary  tumor  appears;  in  fact,  their  presence  should  suggest  the 
presence  of  malignant  disease  of  the  organs  mentioned,  and  when  in 
addition  symptoms  are  present  indicating  grave  disease  of  these  organs 
a  clinical  diagnosis  is  warranted. 

Sarcoma. — Pernice^  reports  six  cases  the  genuineness  of  which  Cullen 
calls  in  question.  In  a  single  case  examined  by  me  the  structure  was 
that  of  similar  tumors  not  infrequently  seen  elsewhere  on  the  abdomen, 
which  though  histologicalh'  fibromas,  ma}-  after  many  years  undergo 
rapid  infiltrative  growth.  The  location  at  the  umbilicus,  as  in  case  of 
the  primary  carcinoma,  would  seem  to  be  accidental. 

Congenital  Anomalies. — These  ma}-  sometimes  result  in  the  forma- 
tion ot  small  tumors  (granulomas)  or  cysts  (omphalomesenteric  cysts) .^ 

1  Bonvolsin,  'these  de  Paris,  1891. 

2  Jour.  Amer.  Med.  Assoc,  191 1,  Ivi,  391. 
^  Die  Nabelgeschwijlste,  Halle,  1892. 

*  R.  Fitz,  Amer.  Jour.  Med.  Sci.,  1884,  l.xxxviii,  30. 


CHAPTER    XXXI  I 
TUMORS   OF  THE   BACK 

The  back  is  the  seat  of  many  tumors  and  granulomas  of  the  skin  and 
subcutaneous  tissue,  and  malformations  of  the  spine  are  not  uncommon. 

Fig.  330 


Papilloma  of  the  back. 
Fig.  331 


Melanomas  of  the  back. 


r  in i.i.oM.is 


\A'i 


Tumors  of  the  Skin.  Papillomas.  I.;ii;ii-  |uciuiuiil;iti-ti  |);i|)illomas 
(Fi^.  330)  WW  nor  int"n(|iunt  in  rhis  siruarion.  Rarciv  rlu\  ukt-rart- 
and  heconu-  caicmoniarous.  l^i^nuiutcl  papillomas  art-  conniion,  and 
art-  not  intri(|iicnrl\  riu-  starting  point  of"  malignant  juiowths.  It  is 
.stattcl  rliar  rlu-  Hat  nuilripk-  k-sion.s  (Fig.  331)  are  less  apt  to  be  followed 


Melanomas  of  tht  back. 


by  malignancy  than  the  solitary  circumscribed  type  (Fig.  332).  The 
latter  type,  according  to  this  view,  should  be  e.xcised  as  a  prophylactic 
measure.  Sometimes  a  diffuse  melanosarcomatosis  (Fig.  333)  appears 
in  the  skin  which  m  a  measure  resembles  the  congenital  type,  but  "can 
be  distinguished  h\  the  history-  of  recent  origin. 


448 


TUMORS  OF  THE  BACK 


Lipomas.— The  upper  part  of  the  back  and  the  back  of  the  neck  are  the 
seat  of  predilection  for  subcutaneous  Hpomas.  They  are  large  lobulated 
tumors  unattached  to  the  skin  and  sometimes  pedunculated  (Fig.  334). 
They  sometimes  reach  huge  dimensions. 

Fig.  333 


At'  * 


3"     i-         »'•»      . 


Diffuse  melanosarcomatosis  of  the  back. 

Fibromas.— Fibromas  situated  within  or  beneath  the  skin  are  not  rare 
upon  the  back.  Less  common  are  the  pedunculated  variety  (Fig.  335), 
which   resemble   the   pedunculated    lipomas   in    general    form,   but    are 


c.ikcixoM.i 


449 


lU-iisc.       S|)()iii.m(()iis  cun-    IS    ()c-f;i.si()n;ill\    ohsciMil    \slu-n    tlu-    vessels 
Ml   tlu-  .11  trIUKiticI    |)(ilulc   hrioiiu    orillldcd. 


I'K;.  ??4 


Kic.  335 


Pedunculated  lipoma  of  the  back.  Pedunculated  fibroma  of  the  back. 

Fig.  336 


Mycosis  fungoides. 

Carcinoma.— Malignant  epithelial  growths   are  not   rarely   seen   about 
the  shoulders.     The^-  form  superficial  spreading  ulcers  with   the  char- 
acteristic dense  border  containing  cancer  plugs. 
29 


450 


TUMORS  OF   THE  BACK 


Granulomas. — Syphilis  and  tuberculosis  not  infrequently  occur  on  the 
back.  The  usual  characteristics  of  these  growths  appear,  as  a  rule, 
with  exceptional  clearness.      Syphilis  in  particular  takes  on  the  typical 


Fig.  337 

>    ^_\^ 

.-^    im 

E;*, " 

■'1 

^ 

•X. 

'  1 

,  \ 

Spina  bifida. 

kidney  form  that  permits  diagnosis  at  a  glance.  Mycosis  fungoides 
(Fig.  336),  though  a  rare  disease,  forms  tumors  on  the  back  more  fre- 
quently  than  elsewhere.      These  tumors  are  usually  flat  with  irregular 

Fig.  338 


Spina  bifida. 

surface,  and  the  epidermis  is  usually  intact,  though  sometimes  ulcer- 
ations take  place.  They  usually  give  a  history  of  progression  and 
regression,  which  distinguishes  them  from  malignant  tumors. 


DLrELorMi:.\T.i!.  ri  moms 


451 


Developmental  Tumors.  I  lu-  usual  t\  pt-  is  spina  bihda  li^s.  337 
aiul  ;tS).  Iliis  forms  an  tiasric  timior  with  constricted  base.  It  may 
be  covered  by  normal  skin  or  by  a  thinned  and  delicate  membrane, 
through  which  the  clear  contents  of  the  tumor  ma\-  be  made  out.  Krue 
teratomas  are  sometimes  observed  in  the  region  of  the  sacrum  'tig. 
339).       rhe\'   differ   from   spina    bifida    by    their  j^reater  densirw       I  rue 

Fic.  339 


Teratoma  of  the  sacral  region. 

dermoids  are  sometimes  noted  in  the  anal  or  sacral  region.  The\'  are 
globular  bogg}'  tumors  attached  to  the  deep  tissues,  but  not  to  the  skin. 
Dermoids  are  sometimes  represented  by  a  simple  fistulous  tract  which 
begins  as  a  deep  dimple  in  the  sacral  region  and  ends  as  a  blind  sac 
near  the  anus.  The  hair  with  which  these  sinuses  are  filled  often  gives 
rise  to  irritation  and  suppuration. 


CHAPTER    XXXIII 

TUMORS   OF   THE   LIVER   AND   GALL-BLADDER 

TUMORS    OF   THE   LIVER 

General  Conception. — Primary  tumors  of  the  liver  are  few  and  of 
little  practical  importance,  but  interest  in  their  diagnosis  has  increased 
since  advancement  in  surgical  technique  has  made  their  removal  pos- 
sible; those  not  amenable  to  treatment  are  of  great  scientific  interest. 
Two  questions  present  themselves  m  the  diagnosis:  Is  it  really  a  liver 
tumor  ?  If  so,  is  it  primary  ?  Some  tumors  of  the  liver  give  evidence 
in  themselves  of  their  primary  nature;  cysts,  for  instance,  are  nearly 
always  primary,  while  many  of  the  solid  tumors  are  closely  simulated 
by  metastatic  tumors.  Primary  liver  tumors  may  be  simulated  not 
only  by  metastatic  tumors  but  also  by  anatomical  deformities,  displace- 
ments, and  general  diseases  which  cause  enlargement  of  the  liver. 

Primary  Tumors  of  the  Liver. — Benign  Tumors. — Benign  tumors 
of  the  liver  are  infrequent,  and  most  of  them  are  merely  pathological 
curiosities,  but  a  few  are  significant  on  account  of  their  size.  They 
may  be  solitar}^  or  multiple,  and  ma}^  be  derived  from  the  parenchyma, 
from  the  bile  ducts,  or  from  the  bloodvessels. 

Adenoma. — Single  Adenomas. — Single  adenomas  do  not  occur  often; 
Caminiti^  having  collected  only  twenty  cases.  They  vary  in  size, 
having  the  appearance  of  miniature  liver  lobes,  and  possibl}^  originate 
from  embryonal  inclusions.  Their  cells  resemble  normal  liver  cells, 
but  lack  their  regular  arrangement.  On  section,  adenomas  resemble 
the  normal  liver  tissue  in  color,  but  since  they  exist  as  isolated  nodules, 
with  but  a  limited  blood  supply,  they  are  not  subject  to  the  vascular 
disturbances  of  the  organ,  and,  therefore,  stand  out  prominently  when 
the  liver  as  a  whole  has  suffered  changes  from  an  altered  circulation. 

Adenoma  of  the  Bile  Ducts. — Like  the  preceding,  these  tumors  are 
rare.  They  arise  from  the  bile  ducts  and  rarely  attain  a  considerable 
size  unless  they  become  cystic,  when  they  may  enlarge  so  greatly  as 
to  fill  a  large  part  of  the  abdominal  cavity. ^  Clinically,  they  are  of 
importance  only  because  of  their  size.  Keen's  case^  was  mistaken  for 
a  movable  kidney.     They  are  sometimes  multiple.^ 

^  Arch.  f.  klin.  Chir.,  1903,  Ixix,  630. 

-  Shattuck,  Boston  Med.  and  Surg.  Jour.,  1900,  cxlii,  427. 

^  Ann.  Surg.,  1899,  xxx,  267. 

*  Von  Hippel,  Virchow's  Arch.  f.  path.  Anat.,  1891,  cxxiii,  473. 


77  .u^M'.s  oi   Till.  1.11  i:i<  ).-,;; 

Miiltiplr  .Idniotna  o/  ///,•  Liirr  i  I'i^.  ,40).  I  luki  this  lu;ul  has  hcen 
(lrs(.i  ihid  a  coiuht  loii  in  which  an  iiurtasf  of  Hhroiis  rissui-  is  associated 
with  an  iiicicasc  iii  the  paniuh\nia  nils.  Ilurc  is  still  a  (iiHVnnci- 
ot  opinion  as  to  which  is  tlu-  piimaiv  process.  C'ornil  and  Ranvicr' 
rej^ard  tin-  ciiihosis  as  rhc  initial  chan<;c.  Otiurs-  lulicNi-  that  tht- 
paiiMuIn  niatons    cvW    piohtciarion    and    tin-    hhioiis-tissuc    increase-   arc 

i-'ic.  ^40 


Multiple  adenoma  of  the  li\er. 

due  to  the  same  cause,  while  Lancereaux'  has  advanced  the  \ie\v  that 
the  cirrhosis  is  but  a  reaction  against  the  proliferating  parenchymal 
cells.  The  chief  interest  of  the  problem  lies  in  rhc  fact  that  this  con- 
dition has  been  regarded'  as  a  midstage  between  cirrhosis  and  primary 


'  Manuel  d'histolofiie  patliolojiiciue,  Alcan,  Paris.  1901,  t.  ii,  p.  438. 

-  Kelsch  and  Keiner,  Arch.  d.  Physiol.,  1876,  iii,  622. 

'  Gaz.  d.  med.,  1868,  xxiii,  646. 

^  Brissaud,  Arch.  fjen.  de  med.,  1885,  ii,  129. 


454  TUMORS  OF  THE  LIVER  AND  GALL-BLADDER 

carcinoma  of  the  liver.  The  cut  surface  of  the  diseased  hver  may  be 
composed  of  regions  of  apparently  normal  cells,  gland-like  areas  which 
have  been  regarded  as  proliferated  bile  capillaries,  and  necrotic  centres 
in  which  no  structure  can  be  made  out.  These  degenerated  areas  are 
most  frequentl}^  seen  about  certain  bloodvessels  which  are  filled  with 
granular  debris,  but  nowhere  by  a  true  clot  (Fig.  341). 

Clinically  the  disease  has  been  described  as  resembling  cirrhosis 
of  the  liver.  I  am  in  full  agreement  with  those  who  would  regard  it 
possible  to  distinguish  it  from  cirrhosis  by  the  well-marked  pain  of  a 

Fig.  341 


': '.'?  "/."»;-•',!  '*?:'.   :-'' 


Primary  multiple  adenoma  of  the  liver,  showing  new  gland  formation,  connective 
tissue,  large  thrombosed  vessel. 

dull  sort,  by  the  absence  of  ascites  at  least  until  very  late  in  the  disease, 
and  by  the  absence  of  those  factors  commonly  regarded  (at  least,  until 
recently)  as  causes  of  cirrhosis.  The  practical  point  in  the  recognition 
of  the  disease  relates  soleh^  to  prognosis.  Many  years  may  elapse 
before  marked  constitutional  disturbances  arise,  and  for  long  periods 
the  disease  may  remain  stationary. 

Angiomas. — Not  infrequently  in  the  course  of  autopsies  small  angiomas 
ranging  in  size  from  that  of  a  pea  to  that  of  a  hickory-nut  are  observed 
in  the  liver.  They  are  usually  situated  immediately  under  the  capsule, 
and  project  in  the  shape  of  a  wedge  into  the  liver.     They  are  some- 


r I  MORS  or  rill:  i.iier  455 

tinus  ilitinit(l\  tiu'.i  |).siil.i  1 1  (1 .  lull  mole  Dficii  ilu\  ;ii(  in  inimcduitc 
ooiu.u't  With  ilu  li\ti  i>;i  I  iiuli\  m.i.  I  lu\  loiin  li\i(l  spots  on  ilu  sur- 
[;uT  ot  tin  li\(i.  .iiul  in  sonic  i,;ists  the  ;iit;i  inimccliatch  ;il)oni  their 
ItonUr  IS  [Mi^nuntccl,  thus  lui^hiciunL:,  then  rontr:ist  to  the  suhstance 
of  thi-  h\ri.  Mu\  ;m'  toinposid  of  h\  jui  |)hisi  u  \i-ssfls  whuh  h:i\e 
iMulii^oMf  \ai\iii}j,  (k-j2,rfts  of  chhitation.  I  siiall\  ih(\  communicate 
witli  tiu'  \eins  onh  ,  tiioii^ii  eii-ctih  anLiionias  ha\(  Incn  ol)scr\ecl 
(\'ircho\\).  ()nl\  tile  hii<;i-r  ones  ha\i-  clinnal  si^nihtance.  Occa- 
sionalK  ,  those  associatiil  with  pigmentation,  |-)artKnhirl\  when  multiple, 
haxi-  heen  mistaken  for  mali<:;nant  nnlanoric  rumors.  Keen'  reports 
four  casis  which  came  to  operation. 

Rari-  J  IMORS  OF  iHi-;  LiNKK.  A  smji;le  example  of  lymphangioma 
IS  to  be  found  m  the  literature.'-  My.xomas  ha\'e  heen  descrihed,  as.  for 
instance,  that  reported  by  Nunn,  which  followed  a  similar  tumor  of  the 
breast.  Rolleston^  is  disposed  to  reiiard  this  as  well  as  other  reported 
cases  as  probably  bel()nij;in^  to  the  sarcoma  m"oup  and  obviousK',  it 
may  be  addetl,  metastatic.  Cases  reported  as  fibromas,  too,  Rolleston 
regards  with  skepticism,  and  believes  that  such  are  more  likel\'  to  be 
syphilitic  growths,  though  he  does  not  deny  the  possibility  of  their 
occurrence.  Lipomas,  according  to  some  authorities,  do  not  occur 
within  the  substance  of  the  liver;  but  small,  fatty  growths  upon  the 
capsule  of  the  liver  which  represent  appendices  epiploicae  detached  from 
the  colon  have  been  reported.  Hanot  and  Gilbert'  report  a  case  of 
embr\oma  of  the  liver,  which,  together  with  Musick's,'^  is  the  onh' 
authentic  reported  case.  A  number  of  extrahepatic  teratomas  which 
attained  a  secondary  attachment  to  the  liver  have  been  reported.'^ 

Disease  of  the  liver  is  one  of  the  most  common  late  manifestations 
of  syphilis.  Large  discrete  tumors  are  not  infrequentl\'  observed;  the\' 
are  sometimes  multiple.  History  of  other  evidence  of  the  existence 
of  the  disease  ma\'  be  of  importance,  but  the  serum  reaction  and  the 
result  of  the  exhibition  of  potassium  iodide  should  be  awaited  in  all 
cases  of  primary  tumor  of  the  liver  in  which  the  existence  of  th  s  disease 
is  a  possibility.  A  microscopic  examination  of  the  excised  tumor  gives 
positive  evidence. 

Lymphatic  nodules  frequently'  occur  in  the  liver  in  the  course  of 
the  lymphatic  diseases.  It  is  still  a  disputed  point  whether  these  are 
metastatic    lymphomatous   grow'ths   or   whether   local    lymphatic    tissue 

^  Loc.  cit. 

-  Marescli,  Zrschr.  f.  Heiik.,  Prague,  1902,  x.\i\,  39. 

■*  Diseases  of  tiie  Liver,  Saunders,  Pfiiladclphia,  1905. 

^  Etude  sur  les  Mafadies  du  Foie,  .Asselin  et  Hou/.eau,  Paris,  1888.  p.  295. 

^Jour.  Patli.  and  Bacteriof.,  1898,  v,  128. 

^  Pye-Smirli,    frans.  l*arli.  Soc,  London,  wxvii,  499. 


456  TUMORS  OF  THE  LIVER  AND  GALL-BLADDER 

is  incited  to  growth  by  the  action  of  a  constitutional  stimulant.  They 
are  commonly  associated  with  leukemia  and  may  be  present  in  the 
absence  of  involvement  of  the  peripheral  lymph  glands.  They  appear 
as  whitish-gray  hemispherical  nodules,  with  moderately  moist  surface, 
projecting  from  the  liver  and  sometimes  palpable  through  the  abdominal 
wall.  On  microscopic  section  they  are  often  mistaken  for  epithelial 
growths.  The}^  occur  most  frequently  in  childhood,  a  period  when 
primary  tumors  are  particularly  rare. 

Malignant  Tumors. — Carcinoma. — Primary  carcinoma,  though  its  fre- 
quency is  variously  estimated,  is  unquestionably  a  rare  disease.  EggeP 
was  able  to  collect  but  163  authentic  cases.  All  cases  arising  from  extra- 
hepatic  structures,  particularly  those  of  the  gall-bladder  and  large  bile 
ducts,  should  be  excluded. 

The  primary  carcinomas  of  the  liver  have  been  divided  for  con- 
venience into  several  groups,  based  chiefly  on  their  gross  appearance: 
(i)  The  massive;  (2)  infiltrating;  (3)  nodular;  and  (4)  carcinomas  with 
cirrhosis.-  It  must  be  added  that  writers  do  not  agree  on  any  classifi- 
cation, and,  indeed,  it  is  often  diflficult  to  place  a  given  tumor  in  any  class. 
A  convenient  classification  on  the  basis  of  microscopic  appearance  is 
that  of  Eggel,  who  distinguishes  those  derived  from  the  liver  cells  and 
those  from  the  small  biliary  ducts. 

1.  Massive. — The  massive  type  appears  as  a  single  tumor,  with  some- 
times a  few  secondary  tumors  about  the  border,  and  ma}^  be  so  large 
as  to  occupy  much  of  the  bulk  of  the  liver.  They  are  sharply  demar- 
cated from  the  liver  substance,  and  for  this  reason  seem  to  warrant 
the  term  cancer  en  amande.'^ 

2.  Infiltrating. — This  type  diff'ers  from  the  preceding  in  that  the  liver 
substance  is  infiltrated  by  the  newgrowth.  There  is  also  an  increase 
m  the  connective  tissue,  so  considerable  as  sometimes  to  simulate  cir- 
rhosis. When  the  formation  of  the  fibrous  tissue  is  abundant  these 
tumors  are  of  slow  growth,  but  sometimes  they  are  more  cellular  and 
grow  rapidly. 

3.  Multiple  Nodular  (Fig.  342). — These  difi^er  from  secondary  growths 
chiefly  in  the  fact  that  there  is  no  primary  carcinoma.  It  is  quite  pos- 
sible that  in  some  of  the  cases  reported  as  belonging  to  this  group  a 
primary  carcinoma  existed,  but  was  overlooked  at  the  autopsy.  The 
findings  at  an  exploratory  laparotomy  are  never  exact  enough  to  warrant 
the  diagnosis  of  primary  multiple  carcinoma  of  the  liver;  nor  is  the 
absence  of  umbilication,  which  is  said  to  be  distinctive  of  secondaiy 
carcinoma,  suflRciently  constant  to  be  of  value  in  diflFerential  diagnosis. 

^  Beitr.  f.  path.  Anat.,  1901,  xxx,  506.  -  Rolleston,  loc.  cit.,  p.  471. 

^  Hanot  and  Gilbert,  Etude  sur  les  Maladies  du  Foie,  Asselin  et  Houzeau,  Paris,  1888, 
p.  8. 


riMfjRs  Of  rill,  ill  ER 


457 


Km;.  34: 


/ 


*-  vVn    , 


^N^ 


«•» 


Priman'  multiple  carcinoma  of  the 
liver. 

It  is  this  type  that  most  closel}' 
resembles  secondan'  carcmoma 
of  the  hver.  The  organ  is  often 
much  enlarged  and  the  surface 
is  rendered  uneven  b}'  numerous 
nodules,  varying  from  a  barely 
perceptible  size  to  the  size  of  a 
fist  or  larger. 

4.  Carcinoma  -zcith  Cirrhosis. 
— This  variety  is  of  extreme 
interest  because  of  the  bearmg 
it  has  on  the  origin  of  an}- 
malignant  process.  In  this  type 
the  tumor  cells  resemble  closely 
the  hypertrophied  cells  seen  in 
cirrhotic  livers,  and  are  believed 
to  be  compensatory;  the  inter- 


V\o.  343 


^ 


f    '-«    «v 


t-    ^> 


<55  '  © 


<?»      ^    «»   ^  *     «      A?     <;» 

Primary  carcinoma  of  the  liver,  showing  large 
liver-like  cells  with  and  without  nuclei. 


Fig.  344 


Primarv      adenocarcinoma     of     the     liver, 
epithelial  cell  columns,  connective  tissue. 


458  TUMORS  OF  THE  LIVER  AND  GALL-BLADDER 

stitial  tissue  shows  the  abundant  increase  of  cirrhotic  Hver.  The  external 
appearance  is  that  of  hob-nailed  liver,  and  the  organ  as  a  whole  is  often 
decreased  in  size.  Various  views  as  to  the  relation  of  the  cellular  and 
interstitial  processes  have  been  expressed,  the  most  important  of  which 
are  the  following:  Hanot  and  Gilbert^  believe  the  processes  to  be 
parallel,  the  result  of  some  common  irritant.  Lancereaux-  believes 
that  the  connective-tissue  increase  is  due  to  a  response  to  the  growing 
epithelium  as  in  any  carcinoma.  The  view  to  which  most  recent  writers 
incline  is  that  of  Eggel.^  He  believes  that  the  process  is  primarily  in 
the  connective  tissue  and  that  the  carcinomatous  proliferation  is  but 
an  exaggeration  of  the  compensatory  hyperplastic  process  which  is  so 
commonly  observed  in  other  situations. 

Microscopic  Appearance. — Carcinoma  derived  from  the  hepatic  cells 
show  their  origin  by  their  resemblance  to  these  cells  (Fig.  343).  So 
close  ma}^  the  resemblance  be  that  in  some  instances,  namely,  in  the 
cirrhotic  type,  the  process  cannot  be  certainly  identified  as  malignant 
unless  some  areas  can  be  found  in  which  the  cells  grow  into  a  vein. 
Usually,  there  are  well-marked  variations  from  the  normal  liver  cells. 
They  are  usually  larger,  often  multinuclear,  and  usually  the  nuclei 
stain  more  deeply  while  the  cytoplasm  is  less  granular;  but  in  some 
instances,  probably  as  evidence  of  beginning  degeneration,  large  granules 
are  distributed  throughout  the  protoplasm.  Not  infrequentl}^,  par- 
ticularly near  the  periphery,  areas  of  cells  smaller  than  normal  are 
encountered.  In  arrangement  the  cells  may  form  solid  nodules  or  may 
be  arranged  in  columns  almost  adenoid  in  appearance  (Fig.  344).  In 
carcinoma  springing  from  the  biliary  ducts  the  cells  are  columnar  or 
cuboidal,  with  a  clear  cytoplasm  and  with  the  nucleus  situated  at  the 
base. 

Sarcoma. — Primary  sarcoma  of  the  liver  has  been  divided  into  groups 
similar  to  those  of  the  carcinomas;  massive,  diffuse,  and  multiple  nodular. 
They  may  be  derived  from  the  connective  tissue,  KupfFer's  cells,  blood- 
vessels, and,  in  some  instances,  from  the  connective  tissue  in  cirrhotic 
livers.  Their  clinical  course  is  variable.  The}^  are  even  more  rare  than 
the  carcinomas,  and  have  been  confused  with  syphilitic  lesions.  Even 
melanotic  primary  sarcomas  of  the  liver  have  been  reported,  but  in 
few  if  an}^  of  them  is  there  ample  assurance  that  the  growths  are 
not  secondaiy;  in  fact,  in  some  of  the  reported  cases  eyes  had  been 
removed  previously  for  melanotic  tumors  of  the  retina.  Nothing  could 
show  better  the  need  for  caution  in  accepting  as  authentic  the  cases 
reported  in  the  literature."* 

1  Loc.  cit.  2  Gaz.  des  Hop.,  1868,  xxiii,  646.  ^  Loc.  cit. 

*  White,  Allbutt's  System  of  Medicine,  iv,  204,  Macmillan,  New  York. 


TUMORS  OF  rm:  I.IIER  459 

Secondary  Tumors  of  the  Liver.  I  mnors  ot  tin-  li\ti  nsultiii^  tioin 
nietastasfs  tiom  the  xaiioiis  niali^iuiiu  growths  ot  otiu-r  organs  are 
anions  rlu-  most  titciiunt  cxpci k  lui-  ol  hoth  surj^fon  and  iiarholoj^ist. 
riu'lr  dtttition  ti(i|iniul\  ;ii\is  i  \  idciuc-  of  the  natun  ot  tin-  jMiniary 
runioi,  and  |iartii.iilai  l\  ol  tlu-  lio|Hlcssnc-ss  ot  cure,  and  aftoids  a  basis 
tor  rlu-  tstiniation  ot  rlu-  dinarion  ot  lite.  I  he  tie()iune\-  ot  iiu-rasrasis 
in  rliis  oi-iian  is  iu)r  enrireh  c-xplanud  h\-  its  vaseulai  ir\  .  I  lure  imist 
1h-  sonu-rhinu  in  rlu-  hioelunucal  properties  ot  rlu-  li\er  tells  wliieh 
makes  rlu-  liw-r  a   taNorahle  seat  ot  growth. 

The  \arious  r\  pes  ot  secondary  tumors  have  .so  much  in  comnu>n  rhat 
separate  consideration  of  them  is  nor  necessar\'.  1  he  appearance  of 
rlu-  primar\  rumor  should  i^ne  e\idencc-  of  rlu-  nature  ot  the  hepatic 
nurastasis,  but  is  not  sufficient  to  determine  it.  I'he  existence  of  a 
malignant  tumor  elsewhere  does  not  indicate  certainly  that  the  hepatic 
tumor  is  of  the  same  character,  since  primary  tumors  of  the  liver  have 
bt't-n  known  to  co-exist  with  mahgnant  tumors  elsewhere  in  the  bod\'. 
Great  caution,  however,  should  be  exercised  in  accepting  a  tumor  of  the 
liver  as  primar\-  when  another  malignant  tumor  exists  somewhere  else; 
in  fact,  it  is  onl\-  w  lu^n  the  hepatic  tumor  is  of  a  higher  order  that 
the  question  of  independent  origin  can  be  entertained. 

Macroscopically,  the  characteristic  of  the  secondary  tumor  of  the 
liver  is  the  spherical  nodules  which  project  from  the  surface  of  the 
liver  (Fig.  S45)  or  lie  embedded  within  its  substance.  The  nodules 
exposed  upon  the  surface  of  the  liver  are  frequently  umbilicated,  a 
condition  which  is  easily  discernible  at  exploratory  operation  and 
sometimes  palpable  through  the  abdominal  wall.  The  absence  of 
umbilication  does  not  count  against  the  secondary-  nature  of  the  tumor; 
they  ma\'  sometimes  be  irregular  in  shape.  They  var}'  from  microscopic 
size  to  the  size  of  the  fist  and  larger,  and  are  nearl}'  always  multiple, 
though  an  occasional  solitary  (Fig.  346)  one  ma}-  be  found.  The  chief 
determining  factor  in  the  diagnosis  of  a  metastatic  hepatic  tumor  is 
the  discovery  of  a  primary  tumor  capable  of  forming  metastases.  Micro- 
scopic evidence  of  similarity  is  an  additional  determining  point.  It 
must  be  remembered  that  when  the  secondary  tumors  are  of  small 
size  they  may  result  in  the  enlargement  of  the  organ  as  a  whole,  which 
ma\'  lead  to  an  error  in  diagnosis;  as,  for  instance,  a  primar\-  carcinoma 
with  metastases  in  the  liver  resulting  in  general  enlargement  of  the 
organ  may  give  the  impression  of  primary  hepatic  disorder  with  con- 
comitant digestive  disturbance. 

Clinical  Manifestations. — The  actual  discovery  of  a  tumor  is  the 
onl\-  symptom  of  decisive  value.  Other  symptoms,  such  as  pain,  jaun- 
dice, and  dropsA',  are  of  too  general  significance  to  be  regarded  as 
primary  evidence.     Dull  pain  is  often  present  and  is  due  to  a  stretching 


460 


TUMORS  OF  THE  LIFER  JXD  GALL-BLADDER 


of  the  capsule  or  to  an  irritation  of  the  capsule  when  the  growth  is  near 
the  surface.  Ascites  is  produced  when  the  large  veins  are  compressed 
or  invaded.  Gastric  disturbance  when  present  is  of  a  secondary  char- 
acter.    The  general  disturbance  is  indefinite;  often  there  is  a  rise  of 


Fig.  345 


Secondan*  carcinoma  of  the  liver  from 
carcinoma  of  the  stomach. 


Metastatic  hypernephroma  of  the  hver. 


temperature,  inconstant  and  variable  in  degree,  but  of  greater  value  is 
an  increase  in  eosinophiles  often  to  lo  per  cent,  or  more. 

Diagnosis. — The  first  step  in  the  diagnosis  is  the  demonstration 
that  the  tumor  is  one  of  the  liver.  Other  tumors  which  may  appear 
in  the  hepatic  triangle,  especially  those  of  the  kidney  and  colon,  and 


riMfJUS  or   Till:   l.ll  ER  461 

also  eviiUiui-  ot  discasi-  of  rlu-  saiiu-  oijians,  must  l)i-  (.M.luclid.  liiHa- 
rioii  ot"  tlu'  (.olon,  tli()u<;li  sometimes  of  value,  is  too  often  tallacicjus  to 
Ih-  clepiiulitl  iipt)n.  I  he  most  reliable  infoiniation  is  gained  by  a  stud}- 
of  the  nu)\enunrs  of  the  suspected  tumor  relative  to  the  movements 
of  the  li\er.  When  tumors  are  intimarel\  artaelud  to  the  liver  the\- 
make  rlu'  tiuirc-  respirator)-  excursion;  \s  In  ii  the\-  are  loosel\-  attached, 
rhe\  la«i  behind.  Kxtrahepatic  tumors  ma\  make  a  part  of  the  excur- 
sion, or,  if  the\-  become  secondaril)-  attached  to  the  liver,  ma\'  move 
with  it;  bur  in  this  case  positive  evidence  can  usuall\  be  elicited  from 
the  or<;an  in  which   they  arise. 

When  a  tumor  is  demonstrated  to  be  of  the  liver,  non-neoplastic 
structures  must  be  excluded,  notabi}-,  anatomical  peculiarities.  Con- 
stricted lobes  and  h\-pertrophies  have  the  same  consistency  as  the 
liver,  and  besides  cause  no  symptoms.  Displacements  are  recognized 
b\-  the  absence  of  the  liver  from  its  normal  location  and  by  the  practi- 
cability of  replacing  it. 

Tumors  of  the  liver  ma}'  be  evident  physicall}'  as  a  single  enlarge- 
ment projecting  from  the  organ,  or  the  liver  may  be  general!}'  enlarged 
and  present  merely  a  nodulated  surface.  The  most  striking  fact  elicited 
b}-  palpation  is  the  densit}'  of  the  tumor  or  the  presence  of  the  nodula- 
tions.  These  signs,  even  in  the  absence  of  other  disturbances,  are  strong 
presumptive  evidence  of  tumor  of  the  liver;  if  there  is  a  marked  increase 
in  the  eosinophiles  the  presumption  is  much  strengthened.  It  is  a  mis- 
take to  believe  that  the  presence  of  eosinophilia  necessaril}-  indicates  a 
parasitic  disease. 

Secondary  tumors  ma}-  give  the  same  signs  as  primar}-  ones,  and  the 
chief  means  of  differentiation  is  to  exclude  primai}-  tumors  elsewhere, 
although  it  ma\-  be  impossible  to  do  so  if  the}'  are  too  small  to  cause 
s\mptoms.  Umbilication  is  often  regarded  as  distinctive  of  secondar}' 
tumors,  but  is  sometimes  seen  in  primary  ones;  it  is  nevertheless  strong 
evidence  of  secondary  growths.  The  gastro-intestinal  tract  is  most 
often  the  site  of  the  primar}-  tumor,  but  the  search  for  a  possible  pri- 
mar}' tumor  must  include  the  examination  of  the  e}'e  for  retinal  tumors, 
the  mouth,  particularly  its  floor,  for  carcinomas,  and  the  urine  tor 
evidence  of  renal  tumors. 

Syphilis  of  the  liver  is  often  mistaken  for  primary  tumors.  1  his 
possibility  should  always  be  kept  in  mind,  and  not  only  should  the 
serological  tests  be  applied,  but  the  therapeutic  effect  of  potassium 
iodide  should  be  tested  also. 

Tumors  of  the  gall-bladder,  which  are  more  frequent  than  primary 
tumor  of  the  liver,  have  a  s}-mptom  complex  of  their  own  iq.  v.). 

Prognosis. — Massive  and  multiple  primary  carcinomas  usually  run 
their  course  in  from  two  to  six  months  after  marked  s}'mptoms  begin. 


462  TUMORS  OF  THE  LIVER  AND  GALL-BLADDER 

It  Is  their  rapidity  that  may  aid  in  excluding  them  from  general  diseases 
attended  by  hepatic  enlargement.  The  adenomas  are  of  indeterminate 
duration  and  many  years  elapse  before  serious  consequences  supervene. 
The  angiomas  are  usually  without  clinical  significance  except  occa- 
sionally from  their  size.  Secondary  tumors  result  fatally  usually  from 
the  effect  of  the  primary  disease,  but  not  infrequently  the  hepatic  com- 
plication is  the  cause  of  death. 

Treatment. — The  successful  removals  of  primary  tumors,  though  few 
in  number,  should  encourage  the  surgeon  to  attempt  operation  in  suit- 
able cases.  In  the  reported  cases  each  operator  has  employed  a  tech- 
nique suited  to  the  case  in  hand.  The  cautery  with  the  ligation  of  the 
larger  vessels  as  practised  by  Keen  has  been  most  frequently  employed 
with  success,  but  the  suture  method  as  recently  improved  seems  to  be 
more  nearly  the  ideal  method. 


TUMORS    OF   THE   GALL-BLADDER 

Primary  carcinoma  of  the  gall-bladder  is  the  most  frequent  of  the 
primary  tumors  of  the  liver  and  its  appendages.  Musser^  reported 
lOO  cases,  and  Futterer^  reports  268  cases.  The  disease  was  associated 
with  gallstones  in  70  per  cent,  of  the  cases.  Whether  the  gallstones 
preceded  or  followed  the  beginning  of  the  malignant  disease  does  not 

Fig.  347 


'*V 


Gall-bladder,  the  site  of  irritation  from  gallstones.     Non-malignant  glandular 

proliferation. 

appear,  though  because  of  the  much  greater  frequenc}'  of  gallstones 
their  preexistence  is  probable.-  The  infrequency  of  malignant  disease 
in  this  much  irritated  organ  is  possibly  due  to  the  frank  inflammatory 
processes  to  which  it  is  liable  (Fig.  347). 

^  Boston  Med.  and  Surg.  Jour.,  1889,  cxxi,  525. 

-  Fiitterer,  Ueber  die  Etiologie  des  Carcinoms,  Bergmann,  Wiesbaden,  1901. 


Ti'MoRs  or  Tin:  c  //./.  lu.innr.R  4r>:i 

Pathology.  ( !;ill-l)l.ulil(  i  (.iininonuis  an-  usuallv  ot  tlu  i.«)luiiui:ir 
r\  |H-,  ;iiui  cills  nKi\  still  show  c\iilencf  of  st-crcton'  activit\',  partitu- 
lail\'  in  tin-  papilla i\  tmin  of  tin-  disease.  I^ut  as  the  disposition  to 
infiitrati-  appears  rlu-  itlls  lost-  tluii  finution  and  become  cuboidal  oi 
spherical,  or  nia\  evt-n  Incoiiu-  Hartriucl,  and  form  vci  irahlc  s<iuainoiis- 
cellcil  carcinoma.'  This  is  rlu-  situation  in  which  a  metaplasia  ot 
columnar  cells  into  scpiamous  cells  has  been  most  ^enerall)'  accepted. 

In  <iross  appearance  thev  resemble  similar  growths  in  the  intestine. 
The  wall  of  the  <iall-bladder  ma\  In  inhlrrated  and  stricture  may  result, 
or  tuntiiform  masses  may  Hll  the  lumen,  leavin^^  the  wall  comparativel\- 
uninvolved.  As  extension  occurs  the  liver  ma\'  be  directl\-  invaded 
or  the  surrounding  abdominal  organs  ma\  become  unoKed  b\  direct 
extension  or  b\  metastasis.  When  there  is  direct  extension  to  the 
intestines  a   hstulous  opening  between  the   two  may  be  formed. 

Carcinoma  of  the  Bile  Ducts  and  the  Papilla  of  Vater.  The  extra- 
hepatic  ducts  are  occasionally  the  seat  of  malignant  growths,  the  most 
frequent  site  being  the  papilla  of  \'ater.  The  lesion  is  reall\-  located 
in  the  duodenum,  but  the  disturbance  produced  is  on  the  part  of  the 
liver  and  is  of  chief  interest  in  connection  with  that  organ,  since  death 
usualh-  results  before  the  tumor  is  large  enough  to  produce  symptoms 
on   the  part  of  the  duodenum. 

Carcinomas  appear  usually  as  small  circumscribed  tumors  project- 
ing into  the  lumen  of  the  gut  about  the  biliary  outlet  duct  and  are 
sometimes  ulcerated.  In  structure  they  are  adenocarcinomas  and  grow 
slowly,  with  little  disposition  to  invade  the  surrounding  tissue. 

Clinical  Signs.  The  early  signs  are  usually  those  caused  b}-  obstruc- 
tion to  the  outflow  of  bile.  Jaundice,  early  and  progressive,  and  un- 
attended by  pain  is  the  most  important  sign.  When  the  tumor  becomes 
of  sufficient  size  to  be  palpable,  its  density  is  characteristic. 

Diagnosis. — Gallstones  in  association  with  carcinoma  of  the  gall- 
bladder may  present  a  history  of  typical  attacks  of  hepatic  colic,  and 
in  these  cases  the  progressive  character  of  the  jaundice  is  suggestive. 
A  palpable  tumor  may  be  mistaken  in  such  instances  for  the  distended 
gall-bladder;  but  it  should  be  remembered  that  although  an  inflamed 
gall-bladder  may  be  firm,  it  is  not  so  dense  as  carcinoma,  nor  is  the  latter 
often  so  smooth  as  a  distended  gall-bladder.  Besides,  an  inflamed  gall- 
bladder is  tender  and  carcinoma  is  not.  Pancreatic  carcinoma,  or 
even  inflammation  of  the  pancreas,  may  give  symptoms  indistinguish- 
able from  those  of  early  malignant  disease  of  the  gall-bladder  and  bile 
ducts. 

Even  at  exploration  an  exact  diagnosis  may  be  difficult.     An  exten- 

1  Deetz,  Vircliow's  Arch.  f.  parh.  Anar.,  iqoi,  clxiv,  381. 


464  TUMORS  OF  THE  LIVER  AND  GALL-BLADDER 

sion  from  the  pylorus  or  duodenum  to  the  gall-bladder  is  more  apt 
to  occur  than  one  from  the  gall-bladder  to  the  pylorus.  Similarh'  a 
tumor  affecting  both  gall-bladder  and  liver  substance  is  almost  certainly 
primary  in  the  gall-bladder. 

Prognosis. — Primary  tumors  of  the  gall-bladder  usually  run  their 
course  m  from  six  to  twelve  months  after  the  onset  of  active  symptoms. 
The  clinical  picture  is  that  of  progressive  cholemia. 

Treatment. — These  tumors  are  theoretically  curable  by  removal, 
but  the  close  association  with  important  structures  and  the  difficulty 
of  early  diagnosis  have  made  successful  operation  exceptional.  There 
is  a  primary  mortality  of  nearly  20  per  cent.^  due  chiefly  to  hemor- 
rhage, which  is  particularly  likely  to  occur  because  of  the  jaundice. 
The  symptoms  may  be  palliated  b}'  drainage  of  the  gall-bladder  or  by 
establishing  a  fistula  when  the  growth  is  located  in  the  papilla. 

^Terrier  and  Auvray,  Chirurgie  du  foie,  Paris,  1901. 


C  II   A  V   \    \:  R     X  X   X    I   \ 

TUMORS  ()!•    rilK  PANCREAS  AND  kl'  IROPI- R  IK  )\KrM 

TUMORS    OF    THE    PANCREAS 

General  Conception.  Because  ol  rlu-  ckcp  siruarion  of  rlu-  i)aiuieas 
Its  rumors  are  usually  hire  of  rec{)<i;iiition,  and,  exeeptrnti;  rlu-  c\  srs,  ha\e 
bur  lirrle  clinical  inreresr. 

Cysts.— Cysts  of  rhe  pancreas  may  In-  j^roduced  by  the  retenrion 
of  secretions  b\'  the  occlusion  of  an  outlet  duct,  or  b)^  active  prolifera- 
tion of  pancreatic  tissue,  or  the}'  ma\'  be  formed  independent  of  the 
pancreas  and  become  attached  to  it  secondarily*  (pseudocysts). 

Types. —  Rhikntion  Cysts. — Cystic  dilatations  of  portions  of  the 
pancreatic  ducts  have  been  observed  to  result  from  occlusion  by  pressure 
of  tumors,  from  glandular  atroph}-,  and  from  cicatricial  contractions. 
In  c)^sts  w^hich  are  large  enough  to  be  of  clinical  importance,  the  mode 
of  origin  is  difficult  to  demonstrate.  These  cAsts  have  been  called 
pancreatic  ranulas. 

Proliferation  Cysts. — Activeh'  growing  multilocuhir  cysts  have 
been  observed  in  the  pancreas,  but  they  are  rare.  They  are  supposed 
to  originate  in  developmental  rests.  FapillarA'  projections  into  the 
cysts,  like  those  in  ovarian  cysts,  have  been  observed,  and  like  them, 
also,  may  undergo  malignant  change. 

Pseudocysts. — Various  traumatic  conditions  may  produce  collec- 
tions of  fluid  attached  to  the  pancreas,  in  which  an  active  participation 
of  pancreatic  tissue  cannot  be  demonstrated.  These  are  the  usual 
pancreatic  cA'sts.  Congenital  cystic  disease  of  the  pancreas  analogous 
to  that  of  the  kidney  and  hver  have  been  reported.^ 

Etiology. — Three  general  groups  of  associated  conditions  have  been 
noted  in  connection  with  the  formation  of  pancreatic  CA'sts:  (i)  A 
severe  trauma  of  the  abdomen  is  sometimes  followed  after  a  brief  period 
b}'  the  development  of  a  tumor  in  the  upper  abdomen;  (2)  a  second 
is  not  associated  with  injury,  but  begins  with  severe  pain,  which  is 
followed  by  the  development  of  a  tumor.  The  nature  of  the  changes 
occurring  at  this  time  are  not  known,  but  the\'  appear  to  be  inflamma- 
tory. They  may  be  reactive  to  the  de^'eloplng  tumor  or,  as  seems  more 
probable,  some  unknown  factor  produces  an  infiammation  which   then 

^  Richardson.  I^oston  Mt-d.  and  Sursi.  Jour..  1895,  cxxxii,  280. 
30 


466  TUMORS  OF  THE  PANCREAS  AND  RETROPERITONEUM 

gives  origin  to  the  tumor.  This  group  probably  has  an  etiology  similar 
to  group  ( i),  but  no  trauma  is  evident,  the  changes  being,  so  far  as  known, 
spontaneous.  (3)  In  the  third  group,  the  tumor  develops  without 
obvious  cause,  without  marked  clinical  symptoms,  and  more  slowly  than 
the  preceding.  They  are  frequently  associated  with  chronic  inflam- 
matory conditions  of  the  pancreas. 

The  pseudocysts  frequently  follow  trauma  with  exudation,  or  are 
the  result  of  pancreatitis  and  the  subsequent  changes.  Jordan-Lloyd 
has  shown  that  some  pseudocysts  are  formed  by  an  injury  with  rupture 
of  the  pancreas  into  the  lesser  peritoneal  cavity  which,  when  the  fora- 
men of  Winslow  is  closed,  becomes  a  shut  sac.  The  rapid  filling  of 
this  cavity  gives  rise  to  the  cysts  which  appear  quickly  after  trauma- 
tism. The  escape  of  pancreatic  fluid  into  the  sac  imparts  to  the  entire 
amount  of  fluid  the  digestive  properties  regarded  as  characteristic  of 
pancreatic  cysts. 

Pathology. — The  true  cysts  are  filled  with  a  fluid  which  varies  from  a 
clear  straw  color  to  blue  black,  but  is  usually  reddish  or  greenish.  The 
color  is  dependent  upon  the  amount  of  blood  present  and  the  changes 
which  the  blood  has  undergone.  Microscopically,  it  contains  red  and 
white  blood  corpuscles,  cells  from  the  walls  of  the  cysts,  and  frequently 
crystals  of  cholesterin.  The  greatest  interest  of  the  fluid  lies  in  its 
digestive  power,  the  measure  of  which  is  a  more  accurate  test  of  the 
nature  of  the  fluid  than  its  chemical  examination.  It  has  been  demon- 
strated that  all  three  of  the  pancreatic  ferments  may  be  present,  an}^ 
two  of  them,  one  only,  or,  rarely,  none  at  all.  The  wall  of  the  cyst  is 
composed  of  a  dense  layer  of  fibrous  tissue  carrying  on  its  surface  the 
posterior  peritoneal  layer  of  the  abdomen  and  usually  a  mesentery 
more  or  less  adherent.  Within  this  is  a  looser  layer  containing  many 
thin-walled  bloodvessels.  About  the  surface  of  the  cyst  wall  portions 
of  pancreatic  tissue  can  usually  be  demonstrated.  In  the  prolifera- 
tive type  there  are  cystic  glandular  compartments  going  out  from 
a  more  central  one.  In  the  pseudoc3^sts  there  is  an  absence  of  pan- 
creatic tissue  in  all  portions  of  the  cyst  wall.  There  is  much  in  the 
pathogenesis  and  pathology  of  these  cysts  which  is  still  imperfectly 
understood,  and  a  careful  examination  should  be  made  of  all  available 
material. 

Symptoms  and  Diagnosis. — A  history  of  trauma  and  of  severe  abdominal 
pain  preceding  the  development  of  tumor  are  always  strongly  sugges- 
tive of  pancreatic  cysts.  The  tumor  is  palpable  as  a  smooth  globular 
mass  between  the  xiphoid  process  and  the  umbilicus.  It  may  be  above 
the  stomach  or  below  the  transverse  colon,  but  is  usually  between  them. 
Its  position  relative  to  these  organs  may  be  determined  by  inflating 
them;  if  they  are  found  to  lie  above  the  tumor  its  position  is  certainly 


riMfjRs  or  THE  I'.im.re.is  407 

r(.tr()|Hi  it()iu;il,  ;iiul  w  lun  this  is  known  to  ht  tiiu  tin  (ii;i};nosis  is 
narrowed  ver\'  materiallv  .  Pancreatic  c\'sts  are  usiiall\  situated  in 
the  median  line,  rarely  to  the  rijiht  and  more  commonl\-  to  the  left, 
and  are  immovahle  hy  manipulation  and  on  respiration.  I  he\'  are 
comnionh  atriiulid  hy  dij^estive  distiii  haiue,  and  lapid  emaciation 
is  noted  in  sonu-  cases.  Korte'  contends  that  rapping  is  not  justified 
or  necessar\  in  an\-  case;  ferments  ma\  he  ahsent  trom  pancreatic 
cysts  and  ma\  he  present  in  small  amounts  in  c\sts  not  pancreatic. 
Wliili  it  cannot  he  denied  that  the  presence  of  pancreatic  fluid  within 
a  c\st  or  of  a  hloody  colored  fluid  would  materially  aid  in  diagnosis, 
\et  the  risks  attendin*!;  puncture  are  too  fiieat  to  warrant  the  procedure. 
The  (.ianjicr  in  tapping  comes  from  the  liahility  of  the  fluid  to  escape 
into  the  peritoneal  cavit\'  after  the  needle  is  withdrawn;  \et  puncture 
immediateh-  preceding;  or  during  the  operation  may  be  permitted. 

Differential  Diagnosis.  Hie  glohular,  smooth  surface  distinguishes 
pancreatic  c\sts  from  solid  tumors  of  this  region.  I  hey  may  be  mis- 
taken for  cysts  of  the  kidney,  but  usually  the  encroachment  on  the 
median  line  and  the  slight  disposition  to  fill  the  groin  e.xcludes  a  renal 
origin.  C\sts  of  the  omentum  or  cysts  below  the  umbilicus  are  not 
attended  by  pain  or  emaciation  and  are  mobile.  When  pancreatic 
cvsts  are  large  the\-  ma}-  extend  to  the  brim  of  the  pelvis  and  simulate 
ovarian  cysts,  but  their  lack  of  connection  with  the  pelvis  is  deter- 
minative. 

Treatment. — Attachment  to  the  abdominal  wall,  with  drainage  either 
at  the  time  of  operation  or  subsequently,  is  the  usual  plan  of  treat- 
ment advised.-  Complete  removal  has  been  practised  in  some  instances 
successfully,  but  the  mortalit}-  after  this  method  has  been  greater 
than  after  simple  drainage.  The  chief  objection  to  drainage  is  the 
irritation  of  the  skin  about  the  w^ound  from  the  passing  of  the  pan- 
creatic fluid  over  it.  Months  are  frequently  required  for  the  hstula 
to  close. 

Solid  Tumors  of  the  Pancreas. — Carcinoma. — Primary  carcinomas  of 
the  pancreas  are  infrequent.  The\'  are  most  frequenti)'  situated  in 
the  head;  but  may  be  located   in   any  part  of  the  organ. 

P.\THOLOGY. — The  scirrhous  t\pe  is  most  common,  but  medullary 
and  cylinder  celled,  and  even  colloid  varieties,  attain  a  large  size  and 
ma\-  retain  the  adenoid  structure.  The}'  may  infiltrate  the  capsule 
of  the  organ  and  spread  diffusely  into  the  tissue  about  it.  Extension 
into  the  duodenum  or  in  the  region  of  the  common  duct  leads  to  early 
jaundice. 

'  Chlrurgische  Krankheiten  des  Pankreas,  Enke,  Stuttgart,  1898. 
-  Senn,  Amer.  Jour.  Med.  Sci.,  1885,  xc,  17. 


468  TUMORS  OF  THE  PANCREAS  AND  RETROPERITONEUM 

Symptoms. — The  disease  begins  indefinitely  with  dull  pains  or  diges- 
tive disorders.  Fatty  diarrhea  and  vomiting,  formerly  regarded  as 
pathognomonic,  are  present  in  a  small  proportion  of  cases  only.  Diabetes 
is  usualh^  a  late  symptom,  since  it  is  not  present  until  a  large  part  of 
the  gland  is  involved.  Jaundice  is  one  of  the  most  frequent  symptoms, 
and  in  carcmoma  of  the  head  of  the  pancreas  comes  early,  and  when 
the  tumor  is  situated  near  the  papilla  is  intense  and  constant.  The 
tumor  has  been  palpated  in  nearly  one-half  the  cases,  and  can  usually 
be  made  out  in  patients  who  are  not  too  fat,  especially  under  general 
anesthesia.  The  tumor  usually  may  be  sought  in  the  median  line,  less 
often  to  the  left  and  still  more  rarely  on  the  right  side.  It  is  usually 
dense,  often  nodular,  and  is  immovable  both  on  manipulation  and 
deep  respiration. 

Diagnosis. — The  jaundice  of  pancreatic  carcinoma  differs  from 
that  of  gallstone  obstruction  in  that  it  is  constant  and  usually  intense, 
even  producing  a  greenish-black  color  of  the  skin,  while  in  the  latter 
the  icterus  is  generally  mtermittent  and  less  intense.  In  tumor  obstruc- 
tion the  gall-bladder  is  usually  distended  so  that  it  is  palpable,  while 
in  gallstone  obstruction  the  gall-bladder  is  contracted  and  not  palpable. 
This  symptom  does  not  difi^erentiate  carcinoma  of  the  pancreas  from 
other  tumors  in  this  region,  particularly  from  those  of  the  papilla  of 
Vater.  The  digestive  disturbance  associated  with  cachexia,  particu- 
larly if  there  is  pressure  upon  the  duodenum,  causes  a  dilatation  of 
the  stomach,  as  in  gastric  carcinoma;  the  differentiation  can  be  made 
only  by  an  examination  of  the  gastric  function  and  careful  considera- 
tion of  the  early  historj^.  It  must  be  remembered,  however,  that  in 
advanced  carcinoma  of  any  region  the  gastric  function  may  be  impaired. 
Hemorrhage  into  the  duodenum  has  occurred  in  pancreatic  carcinoma, 
though  this  symptom  would  ordinarily  speak  for  primary  disease  of  the 
gut. 

Duodenal  and  pyloric  carcinoma  late  in  their  course  produce  a 
jaundice  identical  with  that  described  for  pancreatic  carcinoma.  Chronic 
pancreatitis  is  frequently  associated  with  gall-bladder  disease  which, 
when  accompanied  by  jaundice  produced  by  a  stone  in  the  common 
duct,  may  simulate  pancreatic  carcinoma  very  closely.  The  varying 
intensity  of  the  jaundice  and  the  slowness  of  the  course  speaks  for  the 
benign  malad}^,  but  exploratory  operation  is  often  needed  to  clear  up 
the  diagnosis.  Caution  even  then  is  required,  since  the  chronic  infiam- 
matorj"  processes  of  the  pancreas  ma}^  produce  nodulations,  but  the}' 
are  never  as  dense  as  in  the  scirrhous  carcinoma,  nor  as  large  as  in  the 
softer  varieties  of  malignant  tumors.  The  disturbance  in  pancreatic 
function,  if  present,  gives  the  only  clew  to  the  nature  of  the  disease. 


KETRorLKiroM:.!!.  Tl    MORS  409 

Rare  Forms  of  Tumors  of  the  Pancreas.  S;nc<)m;is  li;i\t  l>ten 
obstTVicl.  Inir  air  |-):irli()l()<!,ii:il  (.uiiosiries  and  wirhour  toi  imilatiil  cliiiKal 
(.ouisc'.  I  lu'  saiiu  ma\  In-  saitl  of  tin  ivtii  laici  adenomas  which  some- 
times ilevelop  in  thi'  islands  ot"  l.an<i,c  rhans.  I  idn  rcniosis  and  syphihs 
ma\-  foini  dthnitc-  tuniois  ot"  the  paiureas  and  wirhour  a  microscopic 
exainin.iiion  nia\  hi'  contusi-d  with  inahi;nanr  tumors.  I  he  granulomas 
usualh   occur  at  an  earlier  age  than  rhe  malif!,nant  rumors. 

Treatment.  Operative  remo\al  ot"  trmiors  of  rhe  pancreas  has  met 
wirh  hur  lirrK-  success,  rhou<i,h  ir  is  rechnicall\  teasdde  ui  carcinoma 
ot"  rlu'  rail.  Carcinomas  ot"  rhe  luad,  closel\  associated  as  they  are 
with  the  intestine  and  imporranr  \essels,  give  ver\-  little  prt^spect  for 
surgical  attack.  Even  if  remo\al  is  possible,  the  loss  of  the  organ  brings 
as  an  almost  certain  accompaniment  a  severe  diabetes.  CofFe\'  has 
proposed  an  ingenious  technique  vvhereb\-  it  is  theoreticall)'  possible 
to  remove  the  head  of  the  pancreas  and  implant  the  body  into  a  pouch 
made  from  the  intestine.  11ie  difficulty  of  the  technique  will  rarelx" 
place  a  malignant  tumor  of  the  pancreas  within  rhe  range  ot  opera- 
tive indication.  Benign  encapsulated  tumors  may  be  shelled  out  when 
discovered.  Palliative  treatment  looking  to  the  relief  of  jaundice  b\- 
means  of  a  cholecystenterostom\-  or  to  the  relief  of  gastric  dilatation 
hv  a  gastro-enterostom\-  has  not  been  attended  with   notable  success. 


RETROPERITONEAL    TUMORS 

Tumors  of  the  kidneys  and  pancreas  are  really-  retroperitoneal  in 
location,  but,  in  addition  to  these,  tumors  are  sometimes  observed 
which  are  developed  from  retroperitoneal  connective  tissue,  lipomas 
and  sarcomas  being  most  frequent.  The\-  form  masses  carrying  the 
posterior  parietal  peritoneum  before  them.  Their  diagnosis  is  sometimes 
suggested  b}-  their  immobility  and  dense  character,  and  b}-  the  tact 
that  they  carr\'  the  hollow^  organs  upon  their  summit.  1  he  difterentia- 
tion  between  them  and  the  tumors  of  the  retroperitoneal  organs  above 
mentioned  is  dependent  upon  their  location  and  the  absence  of  symp- 
toms specitic  of  tumors  of  those  organs.  Certain  diagnosis  must  often 
await  the  exploratory  incision.  \'on  Hippel-  reports  a  case  and  has 
collected  four  from  the  literature  of  retroperitoneal  lymph  c\sts  operated 
for  cysts  of  the  pancreas.  The  diagnosis  was  made  with  the  microscope. 
The  treatment  of  all  of  these  tumors  is  that  of  enucleation  when  this 
IS  possible. 

^  Ann.  .Surii.,  1909,  1,  1238. 

-  Arch.  f.  kiin.  Chir..  1909,  Ixxwiii,  1008. 


CHAPTE  R    XXXV 

TUMORS    OF    THE    DIGESTIVE    TRACT 

CARCINOMA    OF   THE    STOMACH 

On  account  of  its  great  frequenc}^,  malignant  disease  of  the  stomach 
is  the  most  vital  problem  in  practical  tumor  study  of  the  present  day. 
It  presents  two  features  of  preeminent  importance:  (i)  The  perito- 
neum provides  the  stomach  with  a  sort  of  capsule  which  admits  of  the 
extension  of  carcinomatous  growth  by  way  of  the  lymphatics,  but  tends 
to  prevent  it  from  spreading  dilFusel}^  through  the  tissues.  Extension 
is,  therefore,  relatively  late,  and  takes  place  in  well-defined  directions. 
(2)  The  function  of  the  stomach  is  such  that  slight  perversions  result 
in  personal  discomfort,  and  in  malignant  disease  these  changes  are  so 
definite  that  the  condition  may  be  suspected  early.  In  addition,  if 
present  tendencies  of  opinion  regarding  the  relation  between  ulcer  and 
carcinoma  be  true,  a  new  field  is  opened  for  surgical  prophylaxis  in 
malignant  disease. 

Frequency. — The  stomach  is  the  most  frequent  site  of  carcinoma 
in  males,  and  in  females  it  is  exceeded  only  by  the  uterus  and  perhaps 
by  the  mammary  gland.  Probabl}^  Welch's  estimate  cannot  be  improved 
upon.  He^  concludes  that  one-fifth  of  all  primary  carcinomas  are  seated 
in  the  stomach.  Other  authors  place  the  percentage  as  high  as  40  per 
cent,  or  even  higher  (50.2  per  cent,  in  Reich's  Hamburg  statistics). 
The  sexes  are  affected  about  equally,  according  to  some  authors,  but 
others  assert  that  males  predominate.  McGlinn-  reports  121  cases  of 
primar}^  carcinoma  in  2268  autopsies,  of  which  the  stomach  was  the 
site  in  45  (37.2  per  cent.).    Of  these,  32  were  in  males  and  13  in  females. 

Etiology. — The  majority  of  carcinomas  of  the  stomach  occur  after 
forty  years  of  age,  and  the  greater  number  of  these  were  between  the 
fortieth  and  sixtieth  years,  55  per  cent,  according  to  Welch's  statistics. 
Bemoulli^  reports  from  the  literature  11  certain  cases  of  carcinoma  of 
the  stomach  before  the  twentieth  year.  Social  position,  modes  of  living, 
and  external  trauma  exert  little  or  no  influence. 

The   only   etiological    factor   of  known    importance   is    a    preexistent 

^  Pepper's  System  of  Medicine,  Lea,  Philadelphia,  1885,  ii,  533. 
^  Amer.  Jour,  of  Surg.,  1909,  xxxiii,  426. 
^  Arch.  f.  Verdauungskr.,  1907,  xiii,  118. 


c.tR(:i\()\i.i  or  Tin:  stomicii  471 

jiastiK-  ukxi.  Some-  .iiithois'  l>clit.\i-  as  man\  as  70  pti  Lt-iu.  ate  pic- 
ctckil  In  ^astiif  iiliti.  Sippy  places  rlu-  Hjiurcs  at  50  per  ctiir.  Other 
h^Lircs  raiim'  as  low  as  7  per  ctnt.  aiul  111  sonic  ot  the  older  literature 
even  nuuli  lower.  This  j^reat  cli\ersit\'  of  opniion  clepentis  upon  the 
source-  of  the  material  a\  ailahlc-  lor  srucl\  and  upon  the  criteria  demanded 
hetoie  accepting;  such  relationship.  The  early  statistics  were  based 
upon  postmortem  studies,  in  which  it  is  plain  that  the  primary  source 
ot"  the  firowth  has  usuall\  heeii  obliterated.  Kven  in  such  material  it 
was  occasionalh  possible  to  produce  histological  j")root  of  the  relation- 
ship b\   hndinji  an  ed^e  ot  an  ulcer  which  had  not  become  carcinomatous. 

The  recent  advances  in  the  knowledge  of  the  relation  of  carcinoma 
to  ulcer  are  due  to  the  frequency'  with  which  ulcer  is  now  operated 
upon,  thus  permitting  a  positive  diagnosis  to  be  made,  and  to  the  result- 
ing abundance  of  material  for  histological  stud\-.  Our  present  positive 
knowledge  is  based  upon  those  operative  cases  in  which  a  part  ot  the 
ulcer  is  found  by  microscopic  examination  to  be  malignant.  I  he  number 
of  such  cases  is  still  small.  Wilson  and  McCart\-  report  10,  with  case 
histories  and  microscopic  and  macroscopic  illustrations,  and  summarize 
a  hundred  additional  cases.  Borrmann,^  on  the  other  hand,  in  a  most 
painstaking  examination  of  63  tumors,  also  obtained  at  operation,  failed 
to  find  a  single  certain  instance  of  the  implantation  of  carcinoma  upon 
ulcer.  In  order  to  arrive  at  a  satisfactory  knowledge  of  this  relationship, 
cases  in  which  there  is  anatomical  evidence  of  the  establishment  of  car- 
cinoma upon  an  ulcer  should  be  recorded  together  with  a  detailed  history. 
Present  opinion  of  the  frequent  association  of  the  two  lesions  is  based 
largely  upon  the  historj'  of  a  former  gastric  ulcer  in  the  patient  affected 
by  carcinoma. 

Each  investigator  has  his  ow^n  standard  of  symptoms  warranting 
the  diagnosis  of  gastric  ulcer.  Man}-  men  deny  the  existence  ot  hyper- 
chlorhydria  gastrica  and  gastric  neuroses,  both  conditions  presenting 
h\peracidity,  and  call  such  cases  gastric  ulcer.  Such  symptoms  are 
common,  and  to  accept  them  as  pathognomonic  of  gastric  ulcer  is  to 
confuse  the  most  vital  problem  in  the  pathology  ot  the  stomach.  It 
is  obviously  quite  impossible  to  lix  a  standard  which  shall  be  generally 
accepted  as  sufficient  to  warrant  a  diagnosis  of  ulcer  from  the  history, 
though  in  certain  instances,  no  doubt,  the  history  alone  justifies  the 
diagnosis,  but  only  in  the  minority  of  cases.  If  complete  histories  ot 
reported  cases  were  presented  it  would  enable  others  to  judge  the  point 
of  view^  of  the  w-riters.  The  confusion  into  which  this  question  has 
fallen  is  indicated  by  the  fact  that  some  surgeons  believe  that  when  a 

'  Graham  and  W  ilson,  Amer.  Jour.  Med.  Sci.,  1909,  cx.xxiii,  846. 

-Jour.  Amer.  Med.  Assoc,  vol.  liv. 

^  Das  Wachtums  und  die  \  erbreitungswege  des  Magenkarcinoms,  Fischer,  Jena,  1901. 


472  TUMORS  OF  THE  DIGESTIVE  TRACT 

carcinoma  after  resection  or  at  autopsy  presents  an  ulcerated  area 
the  carcinoma  arose  in  an  ulcer.  It  is  needless  to  say  that  such  a 
conclusion  is  unwarranted. 

That  ulcer  should  be  followed  by  carcinoma  in  a  certain  number  of 
cases  but  corresponds  to  our  well-accepted  knowledge  that  an)'  chronic 
irritation  may  be  followed  by  carcinoma.  The  frequenc}'-  with  which 
ulcer  is  followed  by  carcinoma  is  of  greater  importance  than  the  fre- 
quencv  with  which  carcinoma  is  preceded  by  ulcer.  No  statistical 
evidence  bearing  on  this  point  is  at  present  available.  This  phase  of 
the  question  is  of  importance  in  determining  the  advisability  of  pro- 
phylactic resection  of  an  ulcer  which  refuses  to  heal  promptly  under 
general  treatment.  Statistics  concerning  this  problem  must  come  from 
careful  observation  of  communities  over  a  long  period  of  time  and  not 
from  the  case  records  of  gastrologists. 

The  difference  in  general  location  of  carcinoma  and  ulcer  was  formerly 
cited  as  evidence  against  the  implantation  hypothesis;  in  particular 
the  supposed  frequenc}^  of  ulcer  in  the  posterior  wall  and  of  carcinoma 
at  the  pylorus  was  noted.  More  frequent  observations  of  early  carci- 
noma, made  possible  by  recent  advances  in  the  surgery  of  the  stomach, 
seem  to  indicate  that  thy  frequently  begin  on  the  lesser  curvature. 
Since  we  are  not  possessed  of  the  knowledge  of  the  cause  of  either  ulcer 
or  carcinoma,  it  is  possible  that  identical  factors  giving  rise  to  ulcer 
in  the  j'oung  may  produce  carcinoma  in  later  life.  The  frequent  asso- 
ciation of  hyperchlorhydria  with  spontaneous  carcinoma,  considering 
it  to  indicate  an  implantation  upon  ulcer,  may.  be  of  importance  in 
the  estimation  of  the  frequency  of  the  succession  of  carcinoma  upon 
ulcer. 

A  strikingly  large  proportion  of  persons  afflicted  with  gastric  carci- 
noma give  a  history  of  perfect  health  preceding  the  malignant  disease, 
and  are  often  able  to  indicate  the  week  or  month  in  which  their  symp- 
toms began.  In  many  instances  such  patients  give  a  history-  of  gastric 
disturbance  in  early  hfe,  but  seldom  is  the  history  of  such  disturbance 
sufficient  to  warrant  a  diagnosis  of  ulcer.  If  these  cases  of  carcinoma 
are  dependent  upon  ulcer,  they  are  separated  from  it  by  a  long  period 
of  apparent  well-being,  although  from  our  knowledge  of  healed  ulcers 
elsewhere,  we  know  that  but  very  few  develop  carcinomas  when  they 
are  once  healed.  In  addition  to  these  conditions,  the  fact  that  ulcer 
is  a  disease  of  early  Hfe,  while  carcinoma  is  a  disease  of  advanced  life, 
has  prevented  many  from  admitting  the  frequent  association  of  the 
diseases. 

Pathology. — Gastric  carcinomas  are  nearly  always  single.  A  few 
cases  of  multiple  primary  carcinomas  and  a  few  cases  of  metastatic 
tumors  have  been  reported. 


i:.ik(:i\().\i.i  oi   riii:  s7o\i./(:// 


47;; 


Site  of  the  Tumor.  In  tin-  nKiji)iit\  ot  i;iscs  rlu-  site-  is  near  tin- 
pylorus  (  1"  i^;.  34<^).  1  lir  tonmrly  acctprtcl  \ii\\  that  most  carcinomas 
hc'^in  at  rlu-  pylorus  has  been  somewhat  modiHcd  i)\  the  Hnciinj^s  of 
operatois.  ( )hservati()n  of  cases  subjected  to  exploratory  operations, 
in  which  the  carcmoma  is  found  oftenest  on  the  small  curvature,  while 
m  tin-  same  cases  at  postmoircni  the  i)\  lorus  i7ia\'  be  m\'ol\ed,  has 
clone  much  to  chan<i;e  this  \iew.  I  he  majoiitv'  fX^  per  cent.)  occur  at 
the  small  cui"\ature  and  in  the  region  of  the  p\  lorus.  About  10  per 
cent,  occur  at  the  cardiac  end,  and  not  more  than  4  per  cent,  on  the 
greater  cur\ature.  The  extension  circularly  about  the  stomach  is 
more  apt  to  occur  as  the  growth  approaches  the  pylorus,  where  the 
lymph  vessels  begin  to  assume  the  circular  arrangement  characteristic 
ot  the  small  intestine. 

Fic;.  348 


Carcinoma  of  pylorus. 

It  is  commonly  supposed  that  the  growth  does  not  extend  beyond 
the  pA'lorus,  but  the  careful  studies  of  Borrmann^  have  shown  that  this 
is  not  correct.  In  his  series  of  cases  the  entire  growth  was  not  removed, 
because  it  was  assumed  that  extension  in  this  direction  did  not  take 
place.  Furthermore,  as  the  same  author  points  out,  the  duodenal 
border  of  the  tumor  is  apt  to  be  regarded  as  the  pA'lorus,  while,  as  a 
matter  of  fact,  the  true  pylorus  may  have  been  destroyed  b}'  the  tumor. 
To  the  left  the  invasion  is  most  extensive  along  the  lesser  curvature. 
This  extension  may  seem  greater  than  it  really  is  because  contractions 
by  the  grow  th  may  cause  pouching  of  the  unaffected  greater  curvature. 

L  suall}',  in  carcinomas  of  the  stomach,  there  is  simple  atrophy  ot 
the   gastric   mucous  membrane,  irrespective  of  the   site   or  size   of  the 


'  Loc.  cit. 


474 


TUMORS  OF  THE  DIGESTIFS  TRACT 


tumor.  This  causes  the  well-known  anomalies  of  secretion.  Carcino- 
mas which  develop  from  preexistent  ulcers  are  not  attended  by  this 
atrophy. 

Mode  of  Extension. — The  plane  of  extension  is  the  mucosa.  The 
carcinomatous  process  usually  extends  in  the  loose  submucous  con- 
nective tissue  several  centimeters  beyond  the  border  of  the  growth  in 


Fig.  349 


-■^^^r 


^4 

.^"' 

-- 

/**, 


^ 


■'■'m 


. -;^6^ 


1i^ 


^:S^!^^.^i%if 


Adenocarcinoma  of  the  pylorus.  Section 
removed  3  cm.  beyond  the  palpable  border 
of  the  tumor. 


Fig.  350 


Carcinoma   of  the   stomach,    forming   a 
mass  occluding  the  pylorus. 


the  mucous  and  muscular  coats,  as  estimated  by  palpation  (Fig.  349). 
This  is  particularly  evident  in  the  lesser  curvature,  the  extension  being 
in  the  direction  of  the  lymph  channels.  Individual  tumors,  however, 
differ  much  in  this  regard.  Some  have  perpendicular  borders,  with  little 
disposition  to  infiltrate  beyond  them  (Fig.  350);  others  taper  off  gradually 
into  the  surrounding  tissue,  and  some,  indeed,  invade  a  large  part  or  even 


(:.iin:i\().\i.i  ni   rill,  siomicii  475 

tlu'  wholi-  ot"  tin-  stoiiKuli  \\;ill.'  1  Ins  l;isi  t  \  pi-  is  cspi-iKilK  :ipr  to 
fXtiiul  ti)i  Ioiil;  dist.iiuTs  lu\t)iul  tin-  ;ip|);ii(iit  tci  iiiiiKi  t  ion  of  tin-  tumor. 
Ir  ni;i\  iiiuh  tlu  pniioiuiim  ;iiul  Ix  \  ond  ;iiul  iiuoKi-  tin-  siii  i  oiiiulinti; 
()rt;;ins  In    iliiiLi   iiuiision.      I  mkiIK    this  is  ;i   lau-  occm  rciu'c. 

Metastasis.  I'siuilh  i;uli  tumoi  follows  this  sequence  of  exten- 
sion hist.  111  tin-  iiiiu-os;i,  tlun  to  the  hnipli  ^hiiicls,  ;inil  linall\,  h\- 
ilirect  (.•ontiuuous  extension,  to  n(.i«;hhoi  in^  oi<i,;ins  or  throujih  the  hlood- 
vessels  to  distant  ones.  The  uioiip  of  glands  at  the  lesser  curvature 
and  cardia  (superior  *2;astric)  are  most  tn(pKntl\  mxoKcd  m  tumors  ot 
the  Kssei  cur\aruif  and  p\  lorus.  Tiiese  glands  drain  the  {greater  por- 
tion of  the  anterior  surfaces.  The  greater  curvature  toward  the  pylorus 
drains  into  the  inferior  gastric  glands  situated  near  the  pylorus.  1  here 
are  a  few  glands  at  the  greater  cur\ature,  hut  in  the  tundus  they  are 
exceptional.  The  left  supraclavicular  glands  are  sometimes  involved. 
This  occurs  late  and  the  channel  of  extension  has  not  been  satisfactoril\- 
demonstrated.  The  association  of  ovarian  and  gastric  carcinoma  has 
been  repeatedh"  pointed  out,  and  Schnitzler-  regards  metastasis  in  the 
anterior  wall  of  the  rectum  as  typical. 

Extension  may  take  place  through  the  blood  stream,  though  this  is 
rare;  possibly  liver  metastasis  ma\'  occur  through  the  venous  s\stem. 
Diffuse  primary  carcinomas  involving  the  peritoneum  are  usually 
explained  as  due  to  the  escape  of  cells  upon  the  free  peritoneal  surface 
and  their  propulsion  to  the  distant  parts  of  the  cavity  by  peristaltic 
movements.  Some  of  these  cases  seem  better  explained  by  assuming 
an  extension  through  the  blood  stream,  for  the}-  are  really  subperitoneal 
in  location. 

The  disposition  of  individual  tumors  to  extension  and  metastasis 
varies  much.  In  some  there  is  an  earh'  diffuse  extension,  while  others 
terminate  in  an  abrupt  wall.  Those  which  develop  diffusely  are  more 
disposed  to  early  metastasis,  but  this  is  hy  no  means  universal,  for  small, 
well-circumscribed  tumors  may  give  rise  to  early  metastasis.  Individual 
tumors  of  the  different  types  have  varied  so  much  in  their  clinical 
behavior  that  classification  is  a  matter  of  pathological  convenience 
rather  than  of  any  biological  moment. 

Types.  -Medullary  (Figs.  351  and  352). — This  is  the  most  common 
form.  It  grows  more  rapidh'  than  the  other  forms,  and,  as  the  name 
indicates,  tends  to  form  large  masses  which  project  into  the  cavit\-  of 
the  stomach  and  quickly  invades  all  the  la\ers  at  the  base.  As  is  true 
of  medullary  carcinomas  elsewhere,  metastasis  is  early,  and  because 
of  the  poor  blood  supply  to  the  central  portions,  early  breaking  down 

^  Christian,  Ji)ur.  Amer.  Med.  Assoc,  IQO/'  >^1'"^»  650. 
-Mitt.  a.  d.  Cirenztieb.  d.  Mt-d.  u.  Chir.,  iqo8,  xix,  205. 


476 


TUMORS  OF  THE  DIGESTIVE  TRACT 


is  the  rule.     Ulcerations    so   formed    may  invade  the  peritoneum,  and 
vessels  of  considerable  size  ma}^  become  eroded  and  cause  hemorrhage 

Fig.  351 


Fungus  carcinoma  of  the  stomach. 


Fig.  352 


■Js 


!\;S^ji3Sa  !^^^^W5^fif*P; 


w^^-m^ 


*«4^s,^ 


#  '< 


m 


Carcinoma  of  the  stomach  (infiltrating).     Cells  of  varying  size  intermingled  with 

plasma   cells. 

of  more  or  less  gravity.  Smaller  hemorrhages  may  occur  within  the 
substance  of  the  tumor  and  the  altered  blood  may  later  be  confused 
with   melanin. 


c.ik(:i\()M.i  or  Tin:  stom.icii 


477 


Scirrhous  (I'lj:,.  >5>i.  I  Ins  i\|)c  .nul  tlu  f()icj>()iiij;  ;m-  not  sli;ir|)l\- 
iliHiuii  tioni  i-.uli  oilu  I,  ;iiul  then-  is  ol'icii  (liHiiult\  in  ciccidin^  to  uliich 
^roiip  a  ^i\rii  tiinioi  Inlonjis.  Tlurc  is  evidence,  too,  that  a  tiinior 
scirrhous  in  the  hiiinmniii  may  rake  on  rapid  j^rowrli  later  and  become 
disrnutl)  nu-diillai  \  .  In  sexiial  mstaiues  m  m\'  experience  explora- 
toi\  operations  drsclosed  small  ha  id  tumors  with  extensive  h'mphatic 
mvolvement,  and  at  autopsy,  sonu-  months  later,  larji;e  fungoid  tumors 
were  found.  I  lu  t\  pical  scuihous  tumor  forms  a  hard  indurated  mass 
locali/ed  m  one  rej^ion  ot  riu-  sromach,  suiioundm^  the  pvloric  orihce 
or  mvoKint;  a  consideiahle  j^Jition  of"  the  stomach  wall.  \\  hen  this 
type  of   tumor  surrounds  an  orifice,  constriction  of  the  lumen   usuallv 

t^i^-  353 


\ 


K 


Superficial  carcinoma  of  the  stomach:  showing  granular  base  and  indurated  edge. 


results  because  the  fibrous  tissue  tends  to  contract.  The\'  have  little 
disposition  to  ulcerate.  Hemorrhage  is  less  common  in  this  tA'pe  than 
in   the  softer  varieties. 

Colloid. — 1  his  t\'pe  forms  onh'  about  2  per  cent,  of  gastric  carcino- 
mas. Usually  a  considerable  portion  of  the  stomach  is  involved,  and 
the  surrounding  omentum  and  mesentery  are  extensively  invaded,  so 
that  the  tumor  is  frequenth"  palpable.  Metastasis  is  late  because  the 
cells  degenerate  as  well  as  the  connective  tissue.  There  is  little  dis- 
position to  ulceration  and  hemorrhage.  The  scirrhous  and  the  medullar\- 
t\pes  or  secondary  tumors  arising  from  them  may  show  extensive  col- 
loid degeneration  (Fig.  354).  Such  tumors  are  apt  to  overshadow  the 
mother  tumor  in  size. 


478 


TUMORS  OF  THE  DIGESTIVE  TRACT 
Fig.  354 


WM^&mS^:: 


o^v^J 


Metastasis  in  peritoneum;  colloid  carcinoma  of  the  peritoneum:  showmg  colloid  nest 
and  a  few  cells  which  have  escaped  degeneration. 


Fig.  35- 


Adenocarcinoma  ot  the  stomach. 


c.iRcixoM.i  or  Tin:  STOM.ICII  ITD 

Adenocarcinoma.  In  .1  sinall  nimibii  ol  jiasrnc  caniiioiiKis  rlu-  ^hiiulu- 
hii  stiiKiiiii-  nl  ilu  imuoiis  iiuinhi  ;mf  is  iiioK.-  or  less  iiKiintaiiud  and 
tin-  clcstrucrix  I-  ii.iiiik  ol  the-  timioi-  is  iiuiiiilrsrtd  1)\  iiuasion  ot  the 
sill  lomuliiiii  rissiu  .  I  In  \  lii(|iunrl\  (K\ilop  from  I)imi^ii  acknoiiias  and 
from  pol\  i^oid  li\  pel  tiophus  ot  ilu  miuoiis  mcmbiaiu-,  and  are  often 
poUpoid  or  pedunculated  (Fiji;.  355J-  Metastases  m  nei^hbonnfi; 
hniph  Inlands  are  oftin  found  in  which  the  t\'pical  glandular  structure 
is  retained. 

riuie  has  rectiuh  hetn  nuuh  coiuioxersy  as  to  the  ad\isal)ilit\  of 
maintaining  a  separate  j^roup  foi"  the  malif^nant  adenomas  of  the  stomach. 
The  general  disposition  is  to  drop  the  term  entirely,  and  certainly  so 
far  as  glandulai'  tumois  of  the  stomach  are  concerned  its  retention  is 
not  necessarw  In  some  instances,  it  is  true,  glands  with  a  single  la\'er 
of  cells  are  present  over  large  areas  of  the  tumor,  hut  the  usual  adeno- 
carcinomatous  characters  are  present  in  other  portions.  1  he  term 
adenocarcinoma  would  seem,  therefore,  to  meet  almost  all  re(iuire- 
ments,  it  being  remembered  that  the  degree  of  departure  from  the 
normal  gland  t\pe  differs  much  in  different  tumors  and  in  different 
regions  of  the  same  tumor.  These  slight  modifications  have  no  bear- 
ing on  the  clinical  behavior  of  the  tumor. 

Other  Types. —  Squamous-celled  carcinomas  are  sometimes  seen  in  the 
stomach.  These  are  extensions,  continuous  or  discontinuous,  from 
carcinomas  of  the  esophagus.  Melanotic  tumors  have  been  reported 
in  the  stomach,  but  the\'  are  probabh'  aKva\'s  metastatic  and  usually 
sarcomatous  in  character.  Hematin  deposits  have  been  mistaken  for 
melanin. 

Symptoms. — A  person  over  fort}'  years  of  age  w^ho  sufl^ers  from  gastric 
symptoms  which  persist  be\'ond  a  few^  weeks,  particularly  if  they  are 
attended  with  loss  of  weight,  must  be  suspected  of  having  carcinoma 
of  the  stomach  and  the  following  points  inquired  into. 

Disturbance  of  Nutrition. — The  early  impairment  of  the  function  of  the 
stomach  is  manifested  b}'  flatulence,  loss  of  appetite,  and  subsequently 
bv  loss  of  weight.  When  the  tumor  has  permeated  a  considerable 
portion  of  the  stomach  wall,  gastric  digestion  is  obviously  impossible, 
but  even  in  small  tumors  the  interference  with  nutrition  is  out  of  pro- 
portion to  the  size  of  the  tumor.  The  general  health  suffers  from  the 
poison  produced  b\'  the  metabolism  of  the  tumor.  In  other  cases,  so 
insidious  is  the  onset  that  the  stomach  ma\'  not  be  suspected,  and  in  a 
small  proportion  of  cases  nutrition  may  not  be  interfered  with  until 
relativeh'  late,  so  that  the  degree  of  disturbance  of  nutrition  is  by  no 
means  a  measure  of  the  stage  of  the  disease.  Extensive  invasion  may 
take  place  before  there  is  an\'  indigestion,  and  there  may  be  great  con- 
stitutional disturbance  with  a  slight  local  and  no  disseminated  lesion. 
This  is  obvioush'  the  case  when  either  orifice  is  encroached  upon. 


480  TUMORS  OF  THE  DIGEST  I FE   TRACT 

Hemorrhage. — The  erosion  frequentl}-  gives  rise  to  extensive  losses 
of  blood,  which  may  in  themselves  be  fatal,  but  which  usually  merely 
aggravate  the  general  run-down  condition.  Hemorrhage  great  enough 
to  lead  to  the  vomiting  of  blood  is  exceptional.  The  so-called  cofFee- 
ground  vomit  which  played  so  prominent  a  role  m  the  symptomatology 
of  gastric  carcinoma  with  the  older  writers  is  a  late  symptom.  The 
slight  loss  of  blood  determinable  onh"  b}^  the  examination  of  the  stool 
(so-called  occult  blood)  is  much  more  frequent  and  contributes  materially 
to  the  reduction  of  the  patient.  It  is  often  an  early  or  even  the  earliest 
symptom  and  has  been  much  undervalued  as  a  sign  of  early  carcinoma. 

Pain. — The  pain  in  carcinoma  maj^  be  early  or  late.  Usually  there 
is  only  a  feeling  of  flatulence  due  to  disturbance  in  digestion,  and  is 
usually  described  as  discomfort  rather  than  actual  pain.  The  early 
pain  is  due  to  irritation  of  the  nerves  exposed  by  the  ulceration  or 
to  pressure  on  the  nerves  of  the  stomach  wall  by  the  growing  tumor. 
That  it  is  due  to  the  same  conditions  as  the  pain  of  ulcer  is  proved  b}^ 
the  fact  that  it  has  the  same  distribution  and  is  relieved  by  the  same 
measures.  The  pain  due  to  the  invasion  of  the  surrounding  tissue  is 
like  that  of  invading  carcinoma  elsewhere,  lancinating,  radiating,  per- 
sistent, and  bearing  no  relation  to  the  occurrence  of  local  irritation. 
The  latter  type  of  pain  usually  begins  after  the  growth  has  extended 
beyond  the  confines  of  the  organ.  The  character  of  the  pain  may, 
therefore,  give  some  clue  as  to  the  stage  of  the  disease;  an  inconstant, 
burning  discomfort  in  the  beginning,  a  persistent  and  lancinating  pain 
when  invasion  of  nerve-bearing  areas  has  taken  place. 

Tumor. — Tumor  is  rarely  the  first  sign  discovered.  When  first  out- 
lined it  is  well  defined,  dense,  and  usuall}^  smooth,  or  but  slightly  nodular; 
but  later,  when  the  surrounding  tissues  and  organs  are  involved,  it 
may  assume  any  form.  A  palpable  tumor  may  occupy  any  part  of  the 
stomach.  Those  situated  on  the  lesser  curvature  and  m  the  cardia  are 
not  palpable  until  late.  Those  at  the  pylorus  or  in  the  greater  curvature 
mav  be  palpated  earlier,  but  even  here  the  diagnosis  must  be  made 
in  the  majority  of  cases  without  the  discover}^  of  a  tumor.  A  tumor 
situated  at  the  cardia  may  become  disclosed  b}^  exploring  sound  or 
stomach  tube,  while  at  the  pylorus  it  is  manifested  b}^  the  signs  of 
obstruction  and  the  consequent  gastric  dilatation. 

Changes  in  the  Gastric  Content. — The  secondary  atrophy  of  the  gastric 
mucosa  explains  the  perversion  of  gastric  function.  The  classical 
change  is  the  disappearance  of  hydrochloric  acid  and  the  appearance 
of  lactic  acid  and  Opler-Boas  bacilli.  These  signs  are  of  value,  but 
they  have  not  fulfilled  their  diagnostic  promise.  Gastric  carcinoma 
may  be  present  with  but  a  slightly  diminished,  a  normal,  or  even  an 
increased  amount  of  hydrochloric  acid.     This  is  particularly  likely  to 


c./kci  \(j\i  /  n/    rill.  sroM.icii  4si 

l>t  iiiif  when  ilu  (.■.iniiionKi  is  mipl.nitccl  upon  ;in  ulrii.  (  )n  ilu-  otlui 
luind,  tlu  clum^cs  toiiiuily  ii-^iiiclicl  as  parlio^nonioiiii'  of  caiciiioma 
may  In-  |iitscnt  ni  hini<;n  Ksioiis,  notal>I\  in  lonji,-staiulinn  ulcers  which 
lead  ro  px  loiic  stinosis,  and  also  in  cii  tain  m  luiai  diseases,  jiairiciilailv 
peinicioiis  aiuinia  and  Bii^hr's  disease.  The  (.lianas  in  tlu-  ^asliic 
sc-cii'tion  ha\i'  heeii  e\plaiiu-d  in  man\'  \va\s.  iMiieison'  i-oiuiudes 
rhar  the  caicinoniatoiis  stomach  furnishes  a  ferment  which  aids  in 
peptic  diiiestion,  and  it  is  the  presence  of  this  ferment  that  explains 
tlu-  eailv  ahseiUH-  of  h\(lrochloiic  atid;  I  lininurti',  in  discussing  this 
paper,  calls  attention  to  the  fact  that  the  anu)unt  of  hydrochloric  acid 
present  depends  upon  the  location  of  the  carcinoma.  If  the  tunu)! 
destro)  s  tlu-  ow  ntic  cells,  tlu-  formation  of  h\drochloric  acid  will  he 
limited.  (lasrnc  ach\  lia  may  e.xist  for  \on^  periods  without  e\idence 
ot  carcnu)ma  of  the  stomach  or  elsewhere,  jungeiich-  reports  32  cases, 
in  onl\-  2  of  which  was  carcinoma  present. 

The  Blood.  It  has  been  stated  that  a  slight  leukocytosis  varyinji 
from  9000  to  12,000,  particularly  when  not  influenced  by  the  taking 
of  food,  is  of  value  in  diagnosis.  This  has  been  a  ver\'  constant  symp- 
tom in  my  experience,  but  it  is  not  an  early  symptom,  and  it  usually 
indicates  that  an  inoperable  stage  has  been  reached.  A  marked  reduc- 
tion in  henu)globin  is  often  present  even  in  the  absence  of  hemorrhage, 
70  per  cent,  being  noted  frequently  earl)-  in  the  disease;  the  very  low 
hemoglobin  estimates,  however,  usualh'  are  observed  onh'  late  in  the 
disease  unless  there  be  hemorrhage. 

Occasionally,  severe  anemia  ma\-  exist  in  the  absence  of  hemor- 
rhage or  obstruction,  and  when  the  disease  is  still  in  an  operable  stage; 
cases  are  reported  which  were  apparently  cured  b\-  operation  when  a 
severe  degree  of  anemia  existed.  In  some  instances  the  blood  findings 
dominate  the  clinical  picture,  and  may  closel}'  simulate  or  even  be 
identical  with  that  of  pernicious  anemia.  The  cause  of  such  blood 
changes  is  not  clear.  The}'  are  prone  to  be  present  in  small,  slowly 
growing  tumors,  and  Harrington  and  Teacher^  report  a  case  in  which 
similar  changes  were  associated  with  extensive  bone  metastases. 

Diagnosis. — The  diagnosis  of  carcinoma  of  the  stomach  may  be 
considered  under  the  following  conditions:  (i)  When  a  palpable  tunu)r 
is  not  present.  This  ma}'  be  treated  under  two  heads — (a)  when  there 
is  no  obstruction  of  the  orifice,  and  (b)  when  there  is  obstruction.  (2) 
\\  hen  there  is  a  palpable  tumor  present. 

I  (a)  When  there  is  no  demonstrable  tumor  and  no  obstruction  of 
the  orifices  the  diagnosis  must  depend  upon  the  presence  of  the  digestive 

'Johns  Hopkins  Hosp.  Bull.,  1902,  .\iii,  91.  2  jyjgj    Klin..  1909,  vol.  v. 

■''Glasgow  Med.  Jour.,  1910.  Ixxiii,  241. 
31 


482  TUMORS  OF  THE  DIGESTIVE  TRACT 

disturbances,  loss  of  weight,  and  the  general  appearance  of  the  patient. 
Flatulence  and  lack  of  appetite  are  early  signs,  and  there  may  be 
pain  similar  to  that  of  gastric  ulcer.  Frequently  20  or  30  pounds  are 
lost  within  a  few  months,  but  sometimes  the  loss  is  less  rapid.  With 
the  loss  of  weight  is  a  corresponding  loss  of  strength.  The  general 
appearance  of  the  patient  is  often  strongly  suggestive  of  the  condition. 
The  wrinkled,  pale,  pinched  features,  even  before  the  appearance  of 
cachexia,  often  give  the  diagnosis  at  a  glance.  It  is  in  conjunction 
with  these  symptoms  that  the  presence  of  lactic  acid,  Opler-Boas 
bacilli,  and  anacidity  are  of  special  service.  {b)  When  there  also 
are  symptoms  of  obstruction  of  one  of  the  orifices  the  diagnosis  of 
carcinoma  becomes  much  more  probable;  in  fact,  the  spontaneous 
appearance  of  cardiac  or  pyloric  stenosis,  even  in  the  absence  of  other 
symptoms,  is  sufficient  for  a  probable  diagnosis.  When,  however,  obstruc- 
tion is  preceded  by  the  history  of  ulcer,  the  most  careful  examination 
is  necessary  before  an  opinion  can  be  rendered,  and  even  at  exploration 
an  ulcer  at  the  pylorus  with  contractions  may  simulate  malignancy 
very  closely. 

2.  When  a  tumor  is  present  it  usually  causes  some  of  the  phenomena 
just  mentioned,  and,  as  a  rule,  when  it  can  be  palpated  the  diagnosis 
is  easy.  Occasionally  the  discovery  of  a  tumor  brings  the  patient  to 
the  doctor,  but  in  the  majority  of  cases  the  diagnosis  must  be  made 
without  the  demonstration  of  a  tumor.  When  discovered  it  usually 
means,  as  Mikulicz  first  stated,  that  the  case  has  extended  beyond  the 
hope  of  cure,  but  there  are  exceptions  to  this  rule,  particularly  when 
the  growth  is  colloid  in  character. 

Regional  Diagnosis. — The  greater  frequency  of  carcinoma  ot  the 
stomach  in  the  region  of  the  small  curvature  makes  this  the  probable 
site  when  it  cannot  be  demonstrated  elsewhere;  when  at  the  pylorus, 
dilatation  of  the  stomach  gives  positive  signs,  and  when  at  the  cardiac 
orifice  positive  evidence  is  usually  obtained  with  the  stomach  tube. 
Carcinoma  at  the  greater  curvature  is  likely  to  be  palpable  early,  but 
when  confined  to  the  lesser  curvature  the  tumor  may  attain  con- 
siderable size  before  it  can  be  palpated.  When  it  does  not  cause 
obstruction  of  either  orifice  and  is  not  palpable  it  cannot  be  located 
with  certainty,  but  in  such  cases  this  negative  evidence  and  the 
greater  frequency  of  its  occurrence  at  the  lesser  curvature  make  this 
the  probable  location. 

Differential  Diagnosis. — Ulcer. — If  carcinoma  is  implanted  upon 
an  ulcer  there  is  obviously  a  period  when  differentiation  between  them 
is  impossible.  Pain  coming  on  late  after  meals,  sharp  in  character, 
localized,  and  relieved  by  vomiting  or  the  taking  of  food,  is  characteristic 
of  ulcer.     Occult  blood  may  be  present  in  either  disease;  but  when  it 


CARCISOM  I  or   Till:    STOM.ICII  4S3 

c'oiuiiuus  III  spill'  ot  1 1 i;iniuiii ,  c;iitinom;i  should  ht-  strongly  sus- 
pected. In  iilcii  tluic-  IS  li\  piirhl()rli\  (li  i:i ;  in  taniiionia  this  is  seldom 
the  case,  llcer  usualh  |niisius  a  nniittiiu  course;  carcinoma  pro}i;!esses 
witliout  remission.  Loss  of  \Mi;i,ht  and  strength  are  less  noticeahle 
in  ulcii.  I  Icii  is  more  common  m  \  ounji;  |ieisons  and  in  females,  hur 
this  |")oinr  IS  ot  little  value  m  the  consideratitMi  of  a  concrete  case. 

Pernicious  Anemia.  Loss  of  streiif^th,  dif!;estive  disturbance,  and 
hem()rrha<;e  from  the  stomach  aie  present  in  pernicious  anemia,  hut 
there  is  usualL  little  loss  of  wie^ht.  In  carcinoma  the  anc-mia  ma\' 
be  e.xtreme  and  the  hemat()l()<;ical  changes  resemble  closely  those  of 
pernicious  anemia  except  that  me^aloblasts  are  not  present.  Often 
in  pernicious  anenna  there  is  a  history  of  remissions,  while  eaitinoma 
is  progressive.  Hemorrhage  from  the  gums  and  elsewhere  occurs  in 
pernicious  anemia,  but  not  in  carcinoma.  The  facial  expression  lacks 
the  distress  of  carcinoma,  and   the  skin  is  a  deeper  yellow. 

Nephritis. — Examination  of  the  urine  and  the  determination  of  blood 
pressure  will  usually  give  distinctive  evidence;  but  the  presence  of 
arterial  sclerosis  may  long  confuse  the  picture.  When  the  diseases 
are  coincident,  as  often  occurs,  the  differentiation  becomes  additionally 
difficult. 

When  Tumor  is  Present. — The  physical  findings  in  carcinoma  of  the 
stotnach  when  tumor  is  present  are  usually  distinctive:  A  hard  nodular 
mass  in  the  region  of  the  stomach,  usually  above  and  to  the  right,  but 
sometimes  below  or  to  the  left  of  the  umbilicus;  it  is  usuail}'  slightl\ 
if  at  all  movable,  but  there  may  be  considerable  mobility,  particularl\- 
if  located  in  the  greater  curvature.  Usually  the  general  symptoms 
previously  described  are  present  by  the  time  a  palpable  tumor  is  dis- 
covered. The  presence  of  a  palpable  tumor  excludes  ulcer  with  a  great 
degree  of  certaint)',  unless  there  are  complications.  A  tumor  in  the 
epigastric  region  ma}'  or  may  not  be  of  the  stomach;  when  it  is  asso- 
ciated with  gastric  symptoms  it  presumably  belongs  to  this  organ, 
yet  the  functional  symptoms  ma\'  be  an  expression  of  a  malignant  or 
other  tumor  in  neighboring  organs.  Conversel)',  the  discovery  of  a 
tumor  of  the  stomach  may  be  the  first  s\mptom  of  gastric  carcinoma, 
the  patient  having  previously  regarded  himself  as  being  in  good  health. 
It  is  necessary  therefore,  to  examine  each  tumor  independentl\-  of  the 
general  findings. 

Perigastritis. — A  tumor  may  result  from  an  ulcer  of  the  stomach 
which,  before  or  after  perforation,  has  been  walled  off  by  adhesions. 
In  such  cases  of  perigastritis  the  history  of  ulcer  is  usually  elicited, 
and  there  is  evidence  of  an  inflammation,  rigidit\'  of  the  rectus  muscle, 
and  tenderness.  The  tumor  is  usually  less  regular,  less  movable,  and 
less   dense   than   carcinoma,    and    fever  and    pohmorphonuclear  leuko- 


484  TUMORS  OF  THE  DIGESTIFS  TRACT 

cvtosis  ma^■  be  present  in  greater  degree  than  in  carcinoma.  When 
inflammatorv  processes  are  active,  segmental  contractions  of  the  muscles 
ma}'  simulate  tumor. 

Peritoneal  Tumors. — Solid  or  CA'stic  tumors  of  the  omentum  or  inflam- 
mator}'  exudates  ma\'  be  present  in  the  epigastric  region.  Lsuall\'  they 
are  more  movable  than  gastric  tumors.  The  earh^  age  of  the  patient 
frequentlv  suggests  tuberculosis,  while  the  presence  of  general  disturb- 
ance speaks  for  an  inflammatory  process  as  against  carcinoma. 

Carcinomas  in  the  Region  of  the  Stomach. — Carcinomas  which  occur  in 
the  immediate  vicinit}"  of  the  stomach  usually  cannot  be  differentiated 
with  certaint}'.  If  they  are  in  the  duodenum,  the  patient  gives  a  history 
of  pain  late  after  meals  or  early  common-duct  obstruction,  but  in  the 
main  the  symptoms  are  those  of  gastric  carcinoma.  Tumors  of  the 
gall-bladder  may  early  cause  jaundice,  and  when  clearly  palpable  they 
are,  as  a  rule,  easily  recognized.  Carcinoma  of  the  pancreas  ma}^  be 
attended  bv  functional  disturbance,  and  when  in  the  head  of  the  gland, 
by  earlv  jaundice,  but  the  tumor  is  not  movable  by  manipulation  or 
on  respiration.  Carcinoma  of  the  transverse  colon  does  not  give  the 
usual  signs  of  malignancy  in  the  stomach,  and  evidence  of  obstruction 
is  earh'  present.  Inflation  of  the  large  gut  renders  the  tumor  demon- 
strable. Colloid  carcinomas  of  the  stomach  soon  invade  the  colon, 
and  diagnosis  of  the  true  condition  then  depends  upon  the  earh'  history. 

Course  and  Duration. — The  duration  of  a  carcinoma  before  it  pro- 
duces symptoms  is  variable  and  cannot  be  positiveh'  stated.  In  the 
6s  cases  reported  by  Borrmann  the  average  was  about  eight  months. 
The  duration  of  the  disease  is  about  as  long  as  the  incipient  stage,  so 
that  an  average  case  will  run  its  course  in  a  year  and  one-half,  but  the 
course  is  subject  to  interference  by  accidents  such  as  hemorrhage  and 
obstruction.  After  the  patient  is  confined  to  bed  usually  two  or  three 
months  supervene  before  death. 

Prophylaxis. — There  are  enough  positive  data  as  to  the  relation 
between  gastric  ulcer  and  carcinoma  to  make  the  careful  medical  treat- 
ment of  the  former  a  matter  of  great  importance,  but  we  are  not  }'et 
possessed  of  sufficient  knowledge  to  warrant  the  routine  excision  of 
ulcers  with  the  idea  of  preventing  subsequent  malignanc}-.  At  the 
present  time  this  is  an  important  problem  for  study. 

Operative  Diagnosis. — The  necessit}-  of  early  diagnosis  and  the  fre- 
quency- of  early,  though  obscure,  symptoms  justify  exploratory  incision 
whenever  a  gastric  carcinoma  is  suspected.  It  must  be  said  that  too 
often  this  measure  is  delayed  too  long.  When  it  is  obvious  that  a  radical 
operation  would  be  useless,  the  diagnostic  incision  should  not  be  made, 
even  though  it  be  urged  by  the  patient.  Further,  the  incision  is  per- 
missible onl}'  when  the  operator  is  capable  of  making  an  exact  diagnosis 


c./kcixoM.i  or  Tin:  stom.icii  4S5 

from  tin-  i^ioss  ;i|i|n;ii  anri-  ■^\^(\  (.'.in  i-;iii\  out  the  i  csiit  loii  if  this  should 
lu'  iui.H-ss;ii\  .  In  the  i\;imiiKii  ion  ;i  (.cit;!!!)  ch  hnitc  phm  ot  pi  oit-diiK.- 
IS  lU'Ccssai  \  .  It  imist  hist  hi-  ilcciilt-d  wluthti  i;iiiiii()iii;i  hi-  pit-seiu; 
rlien  if  so,  whithii  it  is  o|iii  ahli-,  aiul  HiialU  ,  il  a  ininiamin  iiin-  is 
possible.  1  his  im[ihis  ihi-  i-xaiiiinarioii  ot  thi-  l\  iiiph  L;hiiuls.  if  nor 
radically  operable,  the  need  of  a  iialliatiw  operation  must  hi-  i-onsitii-ied. 
I  he  dia«;nosis  of  f^astnc  laninonia  at  exploratory  opiiation  depends 
upon  rhe  disco\ei\  of  a  tiiinoi,  ami  the  |ii"incipal  lesion  to  be  excluded 
is  indurated  ulcer.  Differentiation  hetuien  tlii-m  is  not  al\\  a\s  possible, 
but  usuall\'  the  diagnosis  is  easily  made  when  carcinoma  is  reall\'  present, 
from  the  small  nodules  of  characteristic  hardness  and  the  more  or  less 
definite  border  at  some  portion  of  the  tumor.  Cjlands  ma\  enlarge  in 
either  condition,  but  in  carcinoma  they  are  denser. 

Other  tumors  of  the  re*!;ion  are  readily  differentiated  when  the  abdo- 
men is  opened.  The  cicatricial  tissue  of  chronic  ulcer  ^ives  the  diseased 
part  a  firmness  that  may  cause  e\en  the  experienced  to  hesitate.  I  leer 
is  often  sharpl\-  localized  when  the  process  ,,  , 

IS  very  chronic  and  the  centre  of  the 
lesion  as  seen  from  the  peritoneal  side 
forms  the  centre  of  radiating  bands. 
Usualh'    the    inflammatoiA'     masses    are 

elastic,    though  dense,   and    the    outlines  ^^ 

are    ever\where    smooth.     When    doubt  :'  .^       ^f 

exists,  the  mass  is  probabl}'  mflamma-  ^Hlm 
tory,  particularh-  when  the  mass  is  in  the 
region  of  the  pylorus.  When  it  is  situated 
on  the  lesser  curvature  the  opposite  prob- 
ably obtains,  and  a  doubtful  lesion  m 
this  situation  is  probabh'  carcinomatous, 
particularly  if  there  are  no  adhesions 
and  if  nodulations  are  present  at  the  periphery  and  small  white  points 
can  be  made  out  in  the  peritoneum.  In  ulcer  a  white  mass  may  be  seen 
with  puckered  centre  (Fig.  356),  and  radiating  lines  extending  out- 
ward from  this.  This  is  often  made  more  apparent  by  putting  the  tissue 
on  the  stretch.  Lund'  makes  the  important  observation  that  when  there 
are  adhesions  to  the  liver  or  pancreas  in  cases  earh'  enough  to  be  doubt- 
ful the  condition  is  probably  ulcer.  When  a  carcinomatous  mass  has 
invaded  the  serous  coat  the  characteristic  white  nodules  usually  rt-nder 
the  diagnosis  easA'.  When  carcinoma  is  implanted  on  an  ulcer  the  fact 
cannot   be   determined    hv   macroscopic   examination,   and    the   surgeon 

^  Jour.  Amer.  Med.  Assoc,  1908,  li,  558. 


^ 


Chronic  ulct-r  of  the  stomach. 


486  TUMORS  OF  THE  DIGESTIVE  TRACT 

will  find  it  profitable  to  rehearse  the  history  of  the  case  and  the  evidence 
furnished  by  gastric  analysis. 

The  diagnosis  of  cancer  having  been  made,  its  operability  depends 
upon  its  relations  to  surrounding  organs.  When  attached  to  other 
structures  by  direct  invasion  it  is  inoperable.  The  colon,  the  pancreas, 
and  even  portions  of  the  liver  have  been  resected,  but  these  operations 
should  be  regarded  as  instances  of  surgical  daring  or  of  operative  skill, 
but  hardly  as  examples  of  good  surgical  judgment,  except,  perhaps, 
in  the  hands  of  the  few  whose  exceptional  skill  exempts  them  from  the 
ordinary  rules  of  practice.  If  the  tumor  itself  is  removable,  the  lymph 
glands  must  be  examined.  If  these  are  involved,  the  chances  for  a  cure 
are  much  lessened,  but  if  all  involved  glands  are  removable,  the  opera- 
tion is  permissible.  The  location  of  the  tumor  gives  the  clue  as  to  which 
gland  group  is  to  be  studied  particularly.  The  glands  of  the  lesser 
curvature,  when  that  portion  and  the  pylorus  are  involved,  are  the 
ones  requiring  special  attention,  and  those  of  the  greater  curvature 
when  that  portion  is  affected.  No  matter  where  the  location  of  the 
tumor,  the  glands  above  the  pancreas  should  always  be  examined,  for 
they  are  often  involved  secondarily. 

When  removal  is  not  possible  the  question  of  palliative  operation 
must  be  considered.  This  consists  of  excision  of  the  growth  when 
irremovable  metastases  are  present,  or  the  performance  of  gastro-enter- 
ostomy.  The  latter  operation  has  not  given  satisfactory  results,  and 
is  seldom  performed.  It  is  indicated,  however,  when  there  is  pyloric 
obstruction  or  great  atony,  even  in  the  absence  of  actual  obstruction. 
In  the  absence  of  these  conditions  gastro-enterostomy  is  not  justifiable. 

The  practice  of  doing  an  anastomosis  whenever  there  is  sufficient 
uninvolved  stomach  area  assumes  that  pyloric  obstruction  will  take 
place  later.  As  to  this,  each  case  must  be  judged  for  itself,  the  situa- 
tion and  character  of  the  growth  being  the  guide.  An  inoperable  car- 
cinoma involving  the  pjdoric  region  may  very  readily  cause  an  obstruc- 
tion later.  The  opinion  that  anastomosis  in  the  absence  of  obstruction 
is  justifiable  in  order  that  the  affected  area  ma}^  be  spared  irritation 
from  the  food  is  not  in  accord  with  present  views  of  the  physiology  of 
the  gastro-enterostomized  stomach  with  patulous  pylorus. 

Treatment. — Curative. — No  other  cure  than  excision  is  known.  The 
general  plan  of  operation  consists  in  the  removal  of  the  growth  and  the 
union  of  the  small  intestine  and  remnant  of  the  stomach.  The  means 
and  manner  of  accomplishing  this  is  a  matter  of  secondary  importance. 
The  mode  and  direction  of  extension,  as  already  described,  make  it 
imperative  that  great  care  be  taken  to  remove  sufficient  healthy  tissue 
along  the  lesser  curvature,  which  means  usually  the  greater  portion 
or  all  of  it,  together  with  any  affected  glands  in  the  neighborhood. 
Much  of  the  fundus  may  usually  be  left. 


S.IRCOM  I   or   Till:    STOM.tCll  4X7 

I  lu  ()|Hiari()ii  usiKillv  cloiu-  at  present  is  occlusion  of  the  duodenal 
stump  as  well  as  the  stump  ot  the  stomach  and  anastoriK^sis  of  the 
jejunum  and  the  lowest  pomt  ot  the  stomach  i  the  second  Hilh(jth 
operation).  Direct  anastomosis  of  duodenum  and  stomach  is  now  rarely 
empl<)\  ed  I  the  Hrst  Billroth  operation).  I  he  use  of  the  clamps  and 
careful  isolation  of  the  operative  field  usually  makes  complete  closure 
of  the  ahtlominal  wound  possdile.  I  lie  detads  ot  the  techiiKjue  may 
he  letr  to  the  judjimenr  and  experience  of  the  operator.  Operations 
of  this  ma<initude  are  not  learned  from  books. 

Palliative  Operation.  In  obstructive  tumors  ot  the  cardiac  end  a 
liastrostonn  shouKl  he  done  before  the  starvation  of  the  patient  has 
rendered  the  ojieration  too  hazardous.  I  he  (operation  must  he  suited 
to  the  size  of  the  stomach,  and  since  the  operation  is  palliati\e  too  much 
time  should  not  be  wasted  on  niceties  of  technicjue.  In  pyloric  stenosis 
gastro-enterostom}-  must  be  done  where  sutficient  healthy  stomach  is 
available.  In  motor  disturbance,  irrespective  of  actual  pyloric  obstruc- 
tion, the  performance  of  the  gastro-enterostomy  at  the  lowest  point 
is  important.  In  the  presence  of  obstruction  of  the  pylorus  without 
sufficient  carcinoma-free  stomach  to  permit  the  performance  of  gastro- 
enterostomy, the  performance  of  enterostomy  alone  remains.  In  this 
operation  the  highest  convenient  loop  of  jejunum  is  stitched  into  the 
abdominal  wall. 

Medical  Palliation. — \\  hen  the  tumor  has  passed  the  operative  stage 
the  use  of  drugs  for  the  relief  of  pain  must  be  considered.  The  coal-tar 
products  should  be  employed  as  long  as  the}'  are  effective,  and  tinally, 
opiates  must  be  resorted  to. 

Results  of  Operation. — Permanent  cures  after  resection  have  com- 
pared favorably  with  those  of  carcinoma  of  more  accessible  regions. 
From  lo  to  20  per  cent,  of  permanent  cures  are  reported  b}'  some  opera- 
tors. The  operative  mortality  lies  between  5  and  30  per  cent,  tor 
the  average  operator  the  latter  is  more  nearly  the  truth. 


SARCOMA    OF   THE    STOMACH 

Sarcomas  of  the  stomach  are  infrequent,  Horsch'  being  able  to  col- 
lect onh'  85  cases  in  the  literature.  They  are  distributed  throughout 
the  various  ages  about  equalh'.  They  show  a  slight  predilection  tor 
the  p3"lorus  and  greater  curvature,  and  vary  in  size  from  a  pigeon's 
egg  to  a  mass  filling  a  large  part  of  the  abdomen.  Secondary  sarcomas 
are  sometimes  observed  in  the  stomach. 

^  Deutsch.  Ztschr.  f.  Chir.,  1907,  .\c,  98. 


488  TUMORS  OF  THE  DIGESTIP^E   TRACT 

Pathology. — All  types  of  sarcoma  have  been  described  with  a  pre- 
ponderance of  round-  and  h'mphoid-celled  t^'pes.  The\'  form  nodular, 
irregular  roundish  tumors,  often  infiltrating  a  considerable  portion  of 
the  stomach.  The  mucosa  is  often  unaffected,  but  it  is  sometimes 
destroyed  and  hemorrhage  results.^  Metastasis  occurs  in  onh'  40  per 
cent,  of  the  cases,  chiefly  in  the  liver  and  spleen,  but  is  sometimes  more 
diffuse,  affecting  the  mesenteric  glands,  kidneys,  and  pericardium. - 

Diagnosis. — Sarcomas  are  characterized  by  severe  pain,  the  large 
size  of  the  tumor,  and  by  the  absence  of  stenosis.  Where  vomiting  of 
blood  occurs  in  a  young  person  when  tumor  is  present,  sarcoma  should 
be  thought  of;  likewise  when  severe  pain  exists  with  the  presence  of  a 
palpable  tumor  unaccompanied  by  the  gastric  and  general  svmptoms 
which  usualh"  attend  gastric  carcinoma  of  like  size.  Gastric  analysis 
has  given  little  information  of  a  positive  nature,  though  hA'drochloric 
acid  IS  less  frequenth^  absent  than  in  carcinoma. 

Treatment. — The  result  of  operation  is  better  according  to  Yates^ 
than  after  carcinoma,  because  the  tumor  is  detected  earh"  and  metastasis 
occurs  late. 

RARE    TUMORS    OF   THE    STOMACH 

Myomas,  fibromas,  and  lipomas  of  the  stomach  have  been  reported. 
Myomas  are  usually  situated  in  the  stomach  wall  and  extend  equalh^ 
into  the  peritoneal  and  stomach  cavities.  Fibromas  may  remain  m 
the  stomach  wall  or  may  form  polypoid  tumors  extending  into  the 
stomach.  Lipomas  usually  lie  between  the  peritoneum  and  muscular 
coats.  These  tumors  are  clmicalh^  unimportant  unless  they  are  located 
at  an  orifice  and  are  large  enough  to  cause  stenosis. 

Polyps  of  the  mucous  membrane  are  sometimes  observed.  They 
form  lobulated  masses  which  project  into  the  lumen  of  the  stomach. 
The}^  are  made  up  of  glandular  tissue,  sometimes  of  small  c^sts.  Like 
those  of  the  intestine,  the}"  are  probabh'  congenital  and  probabh'  rareh' 
become  malignant. 

TUMORS    OF   THE   ESOPHAGUS^ 

The  esophagus  is  the  seat  of  a  great  variety  of  tumors,  but  aside 
from  carcinoma  they  are  all  rarities. 

^  Oberst,  Beitr.  z.  klin.  Chir.,  1905,  xlv,  477. 
^  Clendenning,  Amer.  Jour.  Med.  Sci.,  1909,  cxxxviii,  191. 
^  Ann.  Surg.,  1906,  xliv,  599. 

^  For  literature  see  Selig,  Ann.  Surg.,  1907,  xlvi,  809;  Lamy,  Arch.  de.  mal.  de.  I'app. 
digest.,  1910,  iv,  451;  and  Bryant,  Jour.  Amer.  Med.  Assoc,  1905,  xlv,  2008. 


r I  MORS  OF  THE  ESOril.lC.l'H 


4S0 


Carcinoma.  I'lu-  sin-  of  m;ili<i,n;int  r|)itluli;tl  ^louths  in  this  region 
corresponds  closcl\  to  rlu  iianowisr  |>orti(jns  ui  the  canal,  namely, 
the  pharynx,  the  riaclual  hifurcation,  and  rlu-  cardiac  oriHce.  1  his 
jlives  the  onh"  known  clue  to  etioIofiW  the  piohahilit)-  of  the  uhicjuitous 
factor  of  irritation.  Males  are  said  to  In-  most  often  attected  in  the 
proportion  of  7  to  }.  The  common  t\pe  is  the  stpiamoiis-celled,  though 
colinnnar-celled  carcinoma  may  spring  from  the  glands  m  this  w\L,um. 
rhe\  usually  form  Hat  ulcers  (  Fi^.  357),  which  lead  to  invasion  of  all 
the  coats,  with  subsequent  contraction  and  stenosis,  and  often  per- 
foration   into  tlu-    mediastinum,   with   infection,  or    into  a   bloodvessel, 

KiG.  357 


/ 


Papillary  carcinoma  of  the  esophagus. 

resulting  in  fatal  hemorrhage.  Esophageal  carcinomas  often  form 
early  metastases,  particularh'  in  the  liver,  and  often  at  a  time  when 
the  local  tumor  has  not  yet  given  rise  to  symptoms.  Because  of  the 
hidden  location,  the  metastatic  tumors  are  apt  to  be  regarded  as  the 
primary.  The  esophagus  is  not  infrequent!}'  the  site  of  secondary 
tumors  (Y\g.  358). 

Symptoms. — Stenosis    is    the     most    constant    s\mptom.      Gradually 
increasing   difficulty    in    deglutition    in    a    person    of  carcinoma    age   is 


490  TUMORS  OF  THE  DIGESTIVE   TRACT 

strongl}'    suggestive.      Hemorrhage    spontaneously    or    after    attempts 
at  sounding  often  occurs.     Pain  is  usually  a  late  symptom. 

Diagnosis. — Cicatricial  contraction  usualh^  presents  a  histor}^  ot 
injury  and  is  usuall}'  seen  in  children  or  young  persons.  Spasmodic 
stricture  usualh'  occurs  in  young  neurotic  persons.  The  eye  of  the 
stomach  tube  in  rare  instances  has  brought  forth  bits  of  tissue  which 
have  permitted  a  microscopic  diagnosis,  but  the  only  certain  means 
of  diagnosis  is  by  direct  view  through  the  esophagoscope.  By  means 
of  this  instrument  those  skilled  in  its  use  are  able  to  see  the  lesion,  which 
does  not  differ  from  similar  lesions  elsewhere. 


Fig.  358 


fS''S 


Secondary  carcinoma  of  esophagus:    carcinoma  nodule  within  the  iubmucosa. 

Treatment. — Dilatation  by  means  of  a  sound  may  maintain  a  patulous 
opening.  This  instrument  must  be  emploj^ed  with  great  gentleness, 
for  fear  of  producmg  perforation  and  hemorrhage.  Excision  has  been 
practised  when  the  growth  existed  m  the  cervical  portion,  but  the 
results  have  not  been  gratifAang.  The  treatment  giving  the  most  satis- 
factory results  when  the  openmg  cannot  be  maintained  by  other  means 
is  gastrostomy.  This  permits  the  patient  to  be  fed  until  the  disease 
terminates  fatalh\ 

Rare  Tumors. — The  most  common  of  the  rare  tumors  are  the  polyps. 
The}^  ma}"  become  so  long  that  they  reach  the  pharynx  when  carried 
upward  by  the  effort  of  vomiting.  Usuall}"  the}^  form  masses  which 
interfere  more  or  less  with  deglutition.  When  diagnosticated,  snaring 
through  the  esophagus  has  been  practised.  Cysts  of  the  esophageal 
glands  have  been  observed.     Fibromas  and  myomas  have  been  reported. 


TUMORS  01'  Tim  ISTESTISE 


I'll 


TUMORS    OF   THE   INTESTINE 

I  uMiois  arc  of  (.oiiiiiion  occumiui-  in  tin-  intcsnnal  tract.  N(.arl\ 
S  jHT  c(.nt.  of  all  caicinonias  of  tlu-  l>ocl\  occur  lure  as  c()ni|-»arc(l  with 
20  per  cent,  in  the  stomach;  of  this  niiniher,  about  2.5  per  cent,  are  in 
the  small  intestine.  Nearl\-  50  per  cent,  of  all  intestinal  carcinomas 
are  in  the  sigmoid  anti  lectum,  and  but  slightl\-  less  in  the  cecum  1  he 
predilection  of  carcinoma  for  the  cecum,  sigmoid,  and  rectum  is  believed 
to  be  due  to  the  irritation  from  hardened  feces.  Sarcomas  are  much 
less  frequent,  and  benign  tumors  are  still  rarer,  except  for  the  adenomas 
and  adenomatous  polyps. 

Fig.  359 


'^l!::-''h\. 


^'%. 


Annular  carcinoma  of  the  small  intestine. 


Pathology. — The  intestinal  tumors  do  not  differ  essentialh"  in  their 
pathology  from  those  of  the  stomach.  Carcinomas  of  the  intestine 
are,  as  a  rule,  more  fibrous  than  those  of  the  stomach,  so  that  when 
a  carcinoma  is  arranged  circularly  about  the  gut,  constriction  readily 
takes  place  fFigs.  359  and  360).  Tumors  of  this  type  are  said  to  be 
implanted  frequently  upon  circular  ulcers.  In  the  more  cellular  types, 
with  infiltration  of  the  wall,  degeneration  and  ulceration  may  occur, 
and  the  gut  may  be  occluded  by  subsequent  cicatricial  contraction  of 
the  connective  tissue  at  the  base  of  the  ulcer  (Fig.  361),  or  the  entire 
wall  may  be  thickened  by  the  infiltration  process  (Fig.  362). 

The  entire  thickness  may  be  involved  and  the  surrounding  tissue 
invaded   with    fixation   of  adjacent   organs.      The   involvement   of    the 


492 


TUMORS  OF  THE  DIGESTIVE  TRACT 
Fig.  360  Fig.  361 


Carcinomatous  stricture  of  the  descending  Fungating  carcinoma  of  small  intes- 

colon.  tine. 

Fig.  362 


V 


Infiltrating  carcinoma  of  the  small  intestine. 


r( MORS  or  Tin:  i\ri:sriM. 


49:^ 


ii.i;n)ii  (>t  tin-  hmpli  |i|(\us  cxpLims  the  ilis|)()sit ion  ot  tlusi-  ctllular 
tiiiiiDrs  to  iiur;ist;itu-  foi  iiKiiions,  l)ur  as  t()m|-)ai(.tl  to  laiciiioma  clse- 
uluTf,  imtasrasis  is  iisiiall\  latr.  In  c-onriadisriiurion  to  rhosi-  wliicli 
mhlrrari-  tin-  tirtpci  sirniiun  ot  tin-  wall  an-  the  fuii^ioid  rniiiors 
wlinh  \(U(\  to  loiin  pa|)illoniatoiis  masses  extcnclniii  into  rhc  lunuii 
I  1"  lii.  3(>3'.  iiul  lia\i-  luit  liitir  ciisposirion  to  toiiii  coiistiictioiis  or  to 
iiH-rastasi/r.  I  Ik\  (.onnast  ni  this  icspccr  with  (.arciiioiiias  t-lst-where 
in  tin-  alulonun  wliuli  scattci  imilnpk-  nodiiks  ditiiiseh'  over  rlu-  intes- 
rnu-  and  nusciuci  \  (  Fijz;s.  364  and  365;.  Colloid  cartinonias  occur 
III  rlu-  intisniK'  with  less  rie(]uency  than  in  the  sromach.  I  he\'  do 
not  form  metastases,  hut  spread  e\tensi\tl\  into  nei^hhoiinji  tissues 
'I'lii.  }i^i^).  Pseudom\  xoma  pentoiui  has  heen  reported  as  extenchnj; 
from    rlu-   appendix. 

Fig.  363 


Malignant  paiiillonia  of  the  sigmoid. 


Sarcomas  of  the  intestine  are  much  less  frequent  than  carcinomas. 
They  occur  with  equal  frequencA'  in  the  small  and  large  gut,  and  infil- 
trate a  greater  extent  of  the  gut  wall  and  are  more  prone  to  invade 
the  surrounding  tissues  than  the  carcinomas,  so  that  frequently  the 
point  of  origin  cannot  be  determined.  Fhe  mesentery  and  omentum 
are  particularly-  apt  to  be  invaded.  Stenosis  is  less  likeh'  to  occur  than 
in  carcinoma,  except  when  the  growths  become  very  large;  in  fact, 
instead  of  a  narrowing  of  the  lumen  there  may  be  an  actual  widening 
of  the  affected  portion.  Ordinarily,  sarcomas  run  their  course  in  from 
SIX   to   tweKe   months. 

1  he  pol\  ps  of  the  intestine  are  local  hypertrophies  of  the  mucous 
membrane.      It  is  undecided  whether  these  are  acquired  or  congenital. 


494 


TUMORS  OF  THE  DIGESTIVE   TRACT 


Their  multiplicity  has  been  regarded  as  evidence  of  embryonal  origin 
(Fig.  367).     They  are  sometimes  very  numerous  in  the  rectum  or  ileo- 


FiG.  364 


'"^«,-„ 


/ 


*%-/c^,  , 


Multiple  carcinomatous  nodules  of  mesentery  and  intestine. 
Fig.  365 


section  of  carcinomatous  nodule  of  the  peritoneum. 

cecal  junction,  and  less  frequent  in  the  small  intestine.    They  vary  from 
the  size  of  a  pea  to  that  of  an  egg,  and  may  be  pedunculated.     These 


TCMfJRS  or  THE  ISTESriSK 


495 


tuiiiois  nil-  said  to  lucoim-  m;iliji,n;iiit  at  tinus.  ( )rlui  hiiii^n  riiiiiors 
of  the  intestiiH-  ma\  lu'  n.^arckcl  as  cm  losiriis.  Lij^onias  j^rowinj^  troni 
the  siihnuicosa  ami  ixtciulin^  into  ilu-  hiiiun  of  the  gut  or  beneath 
the  peiitoiuimi  ha\i  hrcii  notid.  Mvoinas  have  been  described  rather 
inore  fi i(]iKiul\  than  lipomas,  hiir  rhe  most  ot  rhi-m  ha\e  been  autopsy 
hndiiiiis.      I\culiar  rhin-walKcl  c\  sts  ma\    occui'  m   rhi-  mtestmal  walls, 


Fig.  366 


Colloid  carcinoma  surrounding  loops  of  intestine. 

and  ma\-  produce  cHnical  symptoms  b\'  direct  occlusion  or  by  invagina- 
tion from  traction  on  the  gut  wall. 

Diagnosis. — The  presence  of  the  tumor  is  seldom  the  first  symptom 
noticed.  L  sualh-  some  indication  of  obstruction  or  ulceration  leads  the 
patient  to  the  ph\-sician,  who  then  in  his  search  discovers  the  tumor. 
When    the   tumor  is   located    high   in    the   intestine,   the   first   symptom 


496  TUMORS  OF  THE  DIGESTIVE   TRACT 

noticed  by  the  patient  is  obstruction  to  the  fecal  current;  when  in  the 
lower  gut,  the  first  s^'mptom  is  ulceration.  The  projection  of  the  tumor 
into  the  lumen  ma_v  subject  it  to  traumatism  with  subsequent  hemor- 
rhage into  the  bowel. 

Pain  ma}'  at  this  time  be  due  to  the  irritation  of  the  surface  of  the 
tumor  hy  the  feces  or  to  cramping  of  the  gut  after  its  lumen  has  been 
partly  occluded.     In  case  of  carcinoma,  it  is  only  after  the  tumor  has 


rh 

Fig. 

367 

^^ 

"^^ 

^ 

■%  ""■ 

•h'--  / 

'^h 

J 

*\  ^'  ■". 

'"^t"  »f,^-" -•'1*'    -    .»^ o^j-^-'i  5        J''*^    "'^- '        ■ '■- 1  V^^  '    "   *' ;',y  .°'*»''-.     *'•""      ''    ■'      ' '■  '     "^ 


^isSSSg 


S^":? 


■     ^-"^'^l.' 


W0kJ^  %  .,  i     :   ^i  '■' 


I--'- 


i,"*^:!x^f    af-      '•'  ■  ^•;- ^  ■:  "  •    '.^  '^^      ^-^^y- . :    '-'•'■. 

Benign  adenoma  of  rhe  intestine  discovered  at  autopsy. 

mvaded  the  surrounding  tissue  that  the  characteristic,  spontaneous, 
lancinating  pain  is  felt.  The  presence  of  obstruction  may  be  first 
noticed  because  of  the  colicky  pains  or  the  increasing  constipation 
which  ma}-  alternate  with  diarrhea.  Fecal  impaction  may  be  the  first 
indication  of  a  beginning  constriction,  and  should  always  be  regarded 
as  presumptive  evidence  of  a  malignant  growth,  and  the  patient  should 
be  watched  carefully  until  the  suspicion  is  verified  or  dispelled.     Often 


rr.Mfjks  or  '////■:  /.\t/:st/.\k  497 

w  lull  rlifir  IS  l>rc-;ikin<;  down  ot  tin-  tumor  tin-  lumen  m;i\  ;i^;im  hccomc 
enlargt'd  and  tin  normal  cuiicnr  reestablished.  Soiiunnies  a  p()l\pf)id 
tumor  diretrfd  up  stream  may  cause  an  intermittent  obstruction  b\' 
acting  as  a  ball  \alve  or  b\  pioduein^;  an  intussusception.  L'olick\' 
|">ains  attended  b\  s\  niptoms  ot  obstruction  should  alwaws  l)e  regarded 
with  <i;rave  suspicion,  particularly  m  persons  at  or  near  middle  hfe. 

W  hen  either  of  the  preceding  s\mptoms,  /.  t\,  obstruction  or  ulcera- 
tion, leads  to  careful  search,  a  tumor  is  often  discovered.  Fre(iuentl\', 
because  ot  the  size  and  situation  of  tin-  tumoi"  or  ot  the  condition  m 
the  abdominal  walls,  it  cannot  be  palpated.  In  such  instances  a  pre- 
sumptive diagnosis  must  be  made  from  the  symptoms  and  an  exploration 
resorted  to.  W  hen  a  tumor  can  be  palpated,  it  is,  in  the  vast  majorit\' 
of  cases,  a  carcinoma.  These  tumors  are  dense  to  the  touch  and  their 
mobility  corresponds  to  the  mobility  of  the  gut  at  the  point  of  attach- 
ment. The}'  do  not  become  absolutely  fi.xed  until  later.  Sarcomas  are 
usually  larger  bosselated  tumors.  Ihe  benign  tumors  rarely  admit  of 
palpation.  Palpation  practised  with  insufflation  usually  demonstrates 
the  general   location  of  the  tumor. 

Localization. — With  the  localization  of  the  tumor,  new  problems 
spring  up  peculiar  to  the  region  involved,  and  regional  consideration 
becomes  imperative. 

The  Small  Intestine. — Less  than  3  per  cent,  of  gut  carcinomas  occur 
in  this  part  of  the  intestine  and  one-half  of  these  are  found  in  the  duo- 
denum. Duodenal  tumors  may  be  confused  with  tumors  of  the  stomach 
and  pancreas.  They  give  rise  to  pain  in  the  right  hypochondrium, 
and  the  tumor  when  palpable  is  located  to  the  right  of  the  median 
line  and  is  not  movable,  contrasting  in  this  respect  with  tumors  of 
the  colon  and  other  parts  of  the  small  intestine.  The  S3'mptoms  var}' 
according  to  the  position  of  the  gut  involved.  When  the  portion  above 
the  papilla  of  Vater  is  affected  the  carcinoma  cannot  be  differentiated 
from  p3"loric  disease  unless  the  location  of  the  tumor  may  give  a  slight 
clue.  \\  hen  the  growth  is  located  below  the  papilla  and  causes  narrow- 
ing of  the  lumen,  there  ma}'  be  vomiting  of  bile  and  pancreatic  fluid; 
this  is  differentiated  from  a  gastrobiliar}'  fistula  b}'  the  presence  of 
trypsin.  When  it  is  located  in  the  region  of  the  papilla  (Fig.  368)  early 
jaundice  usuall}'  occurs,  as  in  carcinomas  of  the  head  of  the  pancreas, 
with  the  difference,  however,  that  in  the  former  the  jaundice  ma\'  be 
intermittent,  while  in  the  latter  it  is  continuous  after  it  once  begins. 
Even  at  explorator}'  inspection  the  differentiation  ma\'  be  difficult. 
In  pancreatic  carcinoma  the  lumen  of  the  gut  is  encroached  upon  bv 
the  bulk  of  the  tumor  in  one  side  of  the  gut,  while  if  the  tumor  arises 
from  the  duodenum,  the  entire  gut  will  be  encircled. 

The  most  prominent  feature  of  tumors  of  the  jejunum  and  ileum 
32 


498  TUMORS  OF  THE  DIGESTIVE  TRACT 

is  obstruction,  and  to  a  less  degree  the  symptoms  of  ulceration.  Usually 
these  attacks  of  obstruction  are  intermittent,  perhaps  with  gradually 
increasing  intensity.  Sometimes  the  onset  of  illness  is  acute.  If  dilata- 
tion and  hypertrophy  of  the  proximal  portion  of  the  gut  takes  place, 
inflammation  from  ulceration  or  other  causes  in  the  region  of  the  tumor 
produces  a  sudden  failure  of  compensation,  with  symptoms  of  acute 
ileus.  The  history  of  attacks  of  obstruction  extending  over  months  or 
j^ears  is  presumptive  evidence  of  the  presence  of  tumor;  but  a  history 
of  gallstones  should  alwaj^s  be  carefully  considered,  for  if  such  be  present 
a  sudden  ileus  points  to  an  obstruction  from  this  cause.  Perichole- 
cystitis also  often  presents  some  of  the  symptoms  of  ileus.  The  por- 
tion of  the  small  intestine  involved  ma}^  be  judged  by  the  time  which 
elapses   between    the   obstruction   and    the   occurrence   of  stercoraceous 

Fig.  368 


X%. 


)' 


Carcinoma  of  the  papilla  of  Vater. 

vomiting;  the  shorter  this  period  the  higher  is  the  disease.  The  tumor, 
when  it  can  be  felt,  is  usually  characterized  by  extreme  mobility.  Sar- 
comas more  often  form  palpable  tumors,  because  not  only  do  they  grow 
more  rapidly  and  larger,  but  the  disposition  to  leave  the  lumen  of  the 
gut  unoccluded  permits  them  to  develop  to  a  greater  size  before  pro- 
ducing serious  symptoms.  The  tumor  is  sometimes  discovered  by  the 
patient  before  subjective  symptoms  have  been  produced.  Usualh^, 
in  intestinal  tumors  the  surgical  diagnosis  of  intestinal  obstruction 
only  can  be  made. 

At  exploration  the  dilated  portion  of  the  gut  points  to  the  seat  of 
the  trouble.  A  carcinoma  usually  forms  a  dense  constricting  ring,  as 
also  may  tuberculosis;  usually,  however,  the  malignant  growth  may 
be  felt  as  a  ridge  on  both  sides  of  the  constriction,  but  this  is  absent 


TiMoks  or  rill:  i\rrsrr\r 


l!l'.) 


in  ml>ci\-ul()sis.  Soiiutiiius  c-an'inomiis  toini  hii^c-  ttmiois  wludi  arc- 
c';isil\  (liaiiiiosticattil  |)\  tluii  iiicnular  appiaraiui-  and  dciisirw  Sar- 
coma iisiiall\  dois  not  raiist-  ohsi  i  lut  ion,  nililiiatrs  carlici,  and  is  softer 
than  carcinoma.  Ihiii^ii  lumois  fiiowmj;  witinn  tin-  j;iii  arc-  fc-It  as 
foreign  bodies.  I  hosi-  Liiowin^  sidiperiroiiealK  and  cncroachinji  on  rlu- 
Innun  ot  tlu'  Li,ut  aic  iico;;nr/cd  as  hcnij;n  1m  iIkm  c-nca|)sularion, 
the  sotter  heinj:;  pi ohaldy  lijiomas  and  rlic  more  cU-nse  nnonias.  Tlu- 
yellowish  color  of  rhc  lipomas  and  the  reddish  color  of  the  nnomas, 
it  unchaniiccl  h\  inHammator\-  piocc-sses,  aids  in  the  detei  nimation  of 
their  nature.  Sometimes  the  occurrence  of  invaj:;inarion  obscures  the 
part  the  tumor  plaws  in  the  condition.  The  henij^n  tumors  are  rarel\- 
palpable  and  cannot  be  diaj^nosticated  other  than  as  a  probable  cause 
of  an  existmti;  intestinal  obst'uction. 

Fig.  369 


?^^>^t^^<^ 


Sarcoma  of  the  cecum:  a,  sarcoma  cells;  b,  muscle  fibers. 


Cecum.- — Nearh'  one-half  the  carcinomas  of  the  intestine  are  found 
in  the  cecum,  usually  at  the  ileocecal  valve  or  immediateh-  above  it. 
Pain  from  narrowing  of  the  lumen  or  hemorrhage  from  ulceration 
are  the  first  sj-mptoms.  Tumor,  when  present,  is  localized,  dense,  and 
more  or  less  movable.  The  diagnosis  is  usuall\-  easy  when  these  symp- 
toms are  present.  When  there  is  pain  alone,  or  pain  with  local  tender- 
ness, an  inflammatorA-  affection  probably  exists.  The  recurring  attacks 
of  colic,  when  obstruction  begins,  ma}-  be  mistaken  for  appendicular 
attacks,  but  the  absence  of  exacerbations,  leukocytosis,  or  rectus  rigidit\- 
should  differentiate  them.  When  chronic  indurative  processes  form 
palpable  tumors  there  is  greater  tenderness.  The  mass  is  movable 
and  the  borders  are  less  defined. 

Sarcomas  of  the  cecum  are  verA"  rare  and  are  usualh'  of  the  round- 


500  TUMORS  OF   THE  DIGESTIVE   TRACT 

celled  variety  (Fig.  369).    The  presence  of  large  masses  without  obstruc- 
tion suggests  the  diagnosis. 

Inflammatory  Masses. — The  region  of  the  cecum  is  the  most  fre- 
quent site  of  inflammatory  exudates  which  may  be  mistaken  for  tumors. 
These  may  be  specific  granulomas  or  the  result  of  inflammatory  pro- 
cesses. They  are  usuall}^  discovered  during  an  operation  supposedly 
for  appendicitis,  and  the  question  of  diff"erentiation  comes  up  during 
the  exploration.  The  inflammatory  masses  are  fixed,  usually  there  are 
adhesions,  and  the  gut  is  generally  uniformly  thickened.  They  are 
never  so  hard  as  carcinoma,  and  are  not  ovoid  or  bosselated  as  sar- 
coma, and  the  transition  to  the  normal  part  is  gradual.  In  tuberculosis^ 
the  miliary  tubercles  are  visible  on  the  peritoneum,  and  the  neighbor- 
ing lymph  nodes  are  often  involved;  they  are  large  and  soft,  as  dis- 
tinguished from  the  dense  glands  in  carcinoma.  For  the  inflammatory 
masses,  there  is  usually  a  history  of  recurrent  attacks  of  inflammatory 
trouble,  most  often  associated  with  the  appendix. 

The  history  is  generally  sufficient  to  distinguish  them  from  ulceration 
and  obstruction.  In  certain  cases  of  appendicitis,  tumor  and  obstruc- 
tion in  the  ileocecal  region  result,  which  simulate  Ytxy  closely  mahg- 
nant  disease.  Tenderness  and  perhaps  rigidity  may  be  present  to  speak 
for  the  inflammator}^  nature  of  the  trouble,  and  age  is  an  important 
consideration.  A  positive  diagnosis  can  seldom  be  made  before  opera- 
tion, though  a  presumptive  one  is  usually  possible.  When  the  region 
is  exposed  by  exploration,  the  diagnosis  should  be  easy.  In  carcinoma 
the  tumor  is  circumscribed  and  dense,  while  the  inflammatory  enlarge- 
ment is  elastic  and  shades  gradually  into  the  surrounding  tissue.  There 
should  be  no  difficulty  in  differentiating  between  an  inflammatory 
adhesion  and  an  adhesion  due  to  the  invasion  of  a  malignant  growth. 
Those  instances  that  have  come  to  my  notice  in  the  laboratory  have 
convinced  me  that  when  the  operator  is  in  doubt  the  disease  is  not 
malignant. 

Not  infrequently  these  inflammatory  masses  are  diagnosticated 
sarcoma  by  the  pathologist.  The  presence  of  numerous  cells  in  close 
relation  to  the  vessels  give  certain  justification  for  such  an  error,  but 
the  presence  of  numerous  polynuclear  leukocj^tes  and  plasma  cells,  and, 
usually,  of  much  fibrin,  should  shield  even  the  novice  from  error.  I 
speak  with  feeling  on  this  subject,  for  it  has  fallen  to  my  lot  to  recognize 
such  masses  as  inflammatory  and  as  curable  by  the  removal  of  the 
appendix.  A  resection  of  the  cecum  performed  by  the  novice  in 
technique  frequently  leads  to  the  death  of  the  patient,  and  when  the 
novice  in  the  laboratory  perpetuates  the  error  of  the  operating  room, 

^  Richter,  Beitr.  z.  Path.  Anat.,  1906,  xxxix,  199. 


riMoks  or  Till-:  i\ri:sri\E 


501 


tlu-   litii  .null'   IS  t;ilsihiil   .iiul   ilu'  ciror  is  tontimud   1>\    otluis  who  :ict 
mull  I    I  In-  false  iiisriiicrion. 

Colon.  ()nl\  ()  pii  cent,  of  iiUtstinal  carcmoniiis  an-  tound  in  this 
portion,  tlu-  lupatic  anil  splinic  llixuns  inin^  rlu-  most  tiiipicnr  sites. 
Ihe  s\  niptonis  are  iisiialh  iiuiiasm^  i-onst!|)ation  anil  ohsti  iiction. 
Sonietinies  a  tiinu)i-  ina\  he  felt,  haul,  nodiilai,  aiul  nioxahle.  i  his  is 
particiilarh'  likely  to  In  the  case  when  located  in  the  transveise  por- 
tion. At  the  splenic  oi  hepatic  anji;les  the\'  are  not  palpable  until  late, 
if  at  all.  Sonutinus  fecal  impaction  ma\  he  felt  instead  of  the  tumor 
which  is  responsible  for  the  impaction.  Sarcoma'  of  the  colon  is  ver\' 
rare.  Tuberculosis  has  been  noted  (  Kij^;.  370).'-'  I'he  ^ut  ma\-  be  affected 
b\  local  ulcerations  or  by  diffuse  infiltration  of  the  ]i\\x  wall.  Inflannna- 
tor\-   thickening  may  cause  confusion. 

Fig.  370 


Chronic  induration  of  the  colon,  probably  tuberculous. 

Sigmoid  and  Rectum.' — This  region  is  more  often  attacked  by  carci- 
noma than  any  other  region  of  the  intestinal  tract,  and  because  of  its 
accessibility  to  palpation  and  inspection,  diagnosis  is  here  most  often 
correctly  made.  Constipation,  painful  defecation,  and  blood  in  the 
stool  are  suspicious  circumstances.  Blood  in  the  stool,  with  increas- 
ing   constipation,    is    very    nearly    pathognomonic.       Lancinating    pain 


'  Jopson  and  White,  Amer.  Jour.  Med.  Sei.,  1901,  cxxii,  807. 
-  Lartigau,  Jour.  Exp.  Med.,  1901,  vi,  23. 

^  Mayo,  W.  J.,   Ann.  Surs:.,  1909,   1,    200,   and    Petermann,   .Arch.    klin.    Chir.,  1908, 
Ix.xxvi,  53. 


502 


TUMORS  OF  THE  DIGESTIVE   TRACT 


is  a  later  symptom,  but  tenesmus  comes  on  relatively  early.  When 
within  reach  of  the  palpating  finger  the  presence  of  the  tumor  may  be 
indicated  hv  masses  springing  into  the  lumen  of  the  gut;  when  beyond 
the  reach  of  the  finger  the  sigmoidoscope  may  bring  it  into  view.  When 
beyond  the  reach  of  direct  inspection,  palpation  in  the  iliac  region  may 
disclose  it.  It  is  here,  as  elsewhere,  dense,  circumscribed,  and  nodulated 
(Fig.  371).  Abscess  and  inflammatory  thickening  are  common,  the 
latter  giving  rise  to  pain  and  constipation.  Sarcoma  of  the  rectum 
is  infrequent,  but  a  large  proportion  of  melanotic  tumors  of  the  rectum 
reported   as   carcinomas   are,  in  fact,  sarcomas.     When  located   in   the 

Fig.  371 


Carcinoma  of  the  sigmoid. 


region  of  the  anus,  metastasis  in  the  inguinal  glands  is  particularly 
likely  to  take  place.  Papillomas  of  the  rectum  (Fig.  372)  are  common 
and  are  a  frequent  source  of  hemorrhage.  Rectal  papillomas  are  most 
commonly  seen  in  children,  and  are  usually  accidentall}^  discovered 
when  they  protrude  from  the  anus.  These  occur  in  early  life,  and  may 
be  congenital.     Often  they  are  found  by  accident. 

Tuberculosis  of  the  rectum  frequently  gives  rise  to  ulcer  and  pain, 
and  may  produce  marked  thickening  of  the  gut  wall. 

Course  and  Termination. — Carcinomas  of  the  intestine  run  a  course 
of  one  or  two  years  after  discovery.  Metastasis  may  form  in  the  regional 
lymph  nodes,    in   the  peritoneum,  and  in  distant  organs,  notably  the 


TiWKJks  or  ////■:  /mkstim-: 


503 


li\(.-i'.  I  In  tumor  in;i\  ^^low  and  ixtciul  Ixvoiul  the  loiihiu-s  ot  the 
intestiiu  aiul  iiuadc  rlu-  soft  ailjaciiit  tissues;  oij^aiis  more  or  less  vital 
iiia\'  he  thus  artected,  such  as  thr  ureters,  the  l)di-  duct,  the  Madder, 
and  thi-  hloodvesseis.  Intestinal  ohstiiiction  is  ottin  iht-  iininediate 
causi-  ot  death,  aiul  fatal  henioiiha^ic  nia\  terminate  the  process,  hut 
more  often  a  condnnation  of  cinumstaiucs  iiKxhucs  (hath  l)\  the 
iiulifinite  state   of   exhaustion. 

Prognosis.  Carcinomas  of  tlie  intistmal  tiact  fuinisli  a  rehitively 
good  prognosis  if  operated  earl)'.  The  natural  walls  of  the  gut  furnish 
an  artificial  capsule,  and  the  relatively  high  type  of  the  cells  does  not 
fit  them  for  early  metastasis.  For  these  reasons  the  operative  prognosis 
is  better  than  in  some  situations  where  a  much  earlier  diagnosis  is  the 

Fic.  372 


KV:>-.:..*^.^ 


•■^v'    "^i-^ 


■^:K'v^fei;n^'^^^ 


Papilloma  of  the  rectum. 


rule.  The  papillary'  t3pe  is  particularly  apt  to  have  a  favorable  out- 
come. Some  of  these  tumors  may  be  said  to  bear  a  similarity  to  certain 
ovarian  papillomas  which  have  been  classed  as  semimalignant.  In 
the  rectum  w'hen  there  is  no  peritoneum  covering  the  gut  this  natural 
encapsulation  is  not  present  and  the  growths  are  ver\'  malignant. 
Fortunately,  diagnosis  in  this  region  is  possible  quite  earl}'. 

Treatment. — Operative  removal  alone  can  afford  the  patient  a  cure. 
The  excision  of  the  diseased  area  and  the  reestablishment  of  the  tract 
are  required.  Each  section  of  gut  naturally  requires  a  technique  of  its 
own.  In  the  small  intestine  a  circular  anastomosis  is  more  certain, 
since  the  proximal  end  is  likely  to  be  too  large  to  make  an  end  approxi- 
mation convenient.  In  the  cecum  a  lateral  anastomosis  between  the 
ileum  and  ascendmg  colon,  after  the  removal  of  the  affected  area,  is 
usualh'  easier  than   an  end   implantation.      In   the  colon   and   sigmoid 


504  TUMORS  OF  THE  DIGESTIVE   TRACT 

a  resection  and  the  formation  of  an  end  junction  may  usualh^  be  done. 
In  the  lower  sigmoid  the  combined  operation  or  one  of  the  sacral 
or  peritoneal  operations  ma}'  be  selected.  The  surgeon  competent  to 
do  these  operations,  will  have  acquired  a  technique  and  experience  of 
his  own  bej'ond  the  power  of  description  to  amplify.  To  others  this 
is  a  forbidden  field. 

Frequently,  when  the  patient  comes  into  the  hands  of  the  surgeon  the 
general  condition  is  such  that  a  radical  operation  is  unsafe  or  useless. 
This  is  usually  the  case  when  acute  obstruction  demands  an  emergency 
operation.  Here  the  surgeon  must  judge  if  it  is  advisable  to  do  a 
temporary  operation  to  relieve  the  obstruction,  and  remove  the  tumor 
later.  Most  surgeons  are  agreed  that  it  is  improper  to  excise  the  tumor 
when  an  acute  obstruction  exists.  An  artificial  anus  or  intestinal  fistula 
may  be  formed  in  a  few  minutes  under  quinine  anesthesia,  and  the 
radical  removal  of  the  growth  and  reestabhshment  of  the  fecal  current 
may  be  undertaken  when  convenient.  The  radical  operation  may  be 
planned  at  the  time  of  the  palliative  operation.  Frequently,  at  the  time 
of  the  emergency  operation,  it  is  evident  that  a  radical  removal  will 
not  be  possible,  and  in  such  instances  the  procedure  will  be  different. 
Thus  in  obstruction  of  the  small  intestine  an  anastomosis  about  the 
growth  may  be  made.  If  it  is  in  the  large  gut  the  entire  gut  ma}^ 
be  severed  and  the  ends  drawn  out  of  the  wound.  These  palliative 
operations  often  are  followed  by  marked  temporary  improvement  due  to 
the  removal  from  the  ulcerated  area  of  the  irritation  of  the  fecal  current, 
and  in  part,  no  doubt,  to  the  obscure  salutary  influence  which  explora- 
tory operations  often  exert  on  these  patients. 


TUMORS    OF   THE    APPENDIX 

Benign  Tumors. — These  tumors  of  the  appendix  are  distinct  varieties, 
and  in  general  do  not  differ  from  similar  tumors  in  other  portions  of 
the  intestinal  tract.  A  few  polypi,  a  single  myxoma,  a  few  myomas  and 
fibromas  have  been  reported.^ 

Sarcoma.^ — Only  a  few  have  been  recorded  in  literature.  In  the 
cases  reported  the  inflammatory  element  predominated  and  the  entire 
picture,  both  anatomical  and  clinical,  suggests  more  a  reactive  h^^per- 
plastic  process.  Against  such  evidence  the  microscopic  picture  must 
be  interpreted  with  great  reserve. 

^  Kelly  and  Hurden,  The  Vermiform  Appendix,  Saunders,  Philadelphia,  1905,  p.  737, 
and   Kelly,  Proc.  Path.  Soc.  Phila.,  1900,  iii,  109. 

^  For  literature  see  Jones,  Trans.  Western  Surg.  Assoc,  191 1,  xx,  49. 


TiMoRs  or  Till-:  .ii'ri:\hi.\  -'^Oo 

Carcinoma.  In  tin-  nciiit  litii;ituii-  ;i  nunihti  of  small  tumors  have 
luiii  ilisc()\<.  rtcl  in  rlu-  ap|>riuli\  which  havr  iisuall\-  been  leKaiclecl  as 
carcinomas.      riu\    aie  iii\aiiahl\    small,   pea    ro  fhcir\'  size,  ot  alveolar 

I'u-  373 


.''rk- 


•   ■        :-^-'.5.  ;..  «-.  T«*te;;  .'n.-:^' -  ~s^  .•^-  --VSi 

--'•'S.'**.    -.     '.    -,.  .    ^   _  -  ^^V-       -_-*.-  -1..  J" 


:>-->^-^: 


"Carcinoma"  o{  the  appendix,  accidentally  discovered  in  sectioning  a  supposedly 

normal  appendix. 

Structure,  show  but  little  tendency  to  invade  the  surrounding  tissue, 
usually  distinctly  expansile  in  growth,  devoid  of  mitotic  figures  or 
cellular  infiltration,  or  other  evidence  of  active  growth  (Fig.  373).  They 
occur  in  young  persons,  and  are  discovered  in  the  routine  of  appendix 


506 


TUMORS  OF  THE  DIGESTIf'E   TRACT 


extirpations.  The}'  have  not  been  the  primaiy  cause  of  operation, 
and  in  onh'  a  few  cases  has  there  been  extension  to  the  mesentery, 
metastasis,^  or  recurrence. 

It  is  obvious  from  the  foregoing  that  these  tumors  present  a  hfe 
history  which  differs  materially  from  the  histor}^  of  typical  carcinomas 
of  young  persons,  and  which  has  led  some  observers  to  deny  them  a 
place  with  carcinomas.  Oberdorf  has  suggested  the  provisional  use 
of  the  term  cancroid.     Milner  goes  so  far  as  to  deny  any  relationship 

Fig.  374 


Carcinoma  of  cecum  and  appendix. 

with  carcinomas  and  to  deny  that  undoubted  cases  of  carcinoma  have 
been  reported.  He  believes  that  the  tumor  represents  endothelial 
proliferation,  the  result  of  inflammatory  processes,  or  of  displaced 
epitheHum,  the  result  of  suppurative  processes.  Because  of  the  micro- 
scopic and  clinical  characters  above  enumerated,  it  seems  to  me  that 
this  view  is  reasonable.     When  there  is  a  perforation  or  a  deep  ulcera- 


^  Le  Conte,  Ann.  Surg.,  1908,  xlvii,  1000. 


77  MfJRS  or   Till.     ll'I'IAhlX  5()7 

iioii  in  till  mil  w.ill,  iht  |>!(  )Iilt  1 .1 1  iiiLi  iiiiu'os.i  i(ii(ls  to  till  III  ilii-  j;;!]) 
Iftr  111  (111  siiImiiiiii  is.i  .iiul  111  iisiiil.i  I  III  f,  ;iii(l  wlicii  ilic  IiciIiiil:  piocesses 
AVv  i"om|il(i  (  il   .1   pu'iiiii    I  (  s(  iiiMi  ml:,  i(  lliil.ii    iiujsioii    is   piocliiccd. 

Muse  lesions  l.uk  till  1 1  )iiiul-i(  ll(  (I  iiitil  M  .1 1 1(  III  ;tiul  fliaii^;c*  m  cell 
t  \  [H  Idiiiul  III  poll  lit  i.ilU  in;iliL:,ii;iiii  irlliil.n  iiuasions,  :iiul  tlu-  <i)n- 
lU'CtiNf  rissiK-  iloi'S  not  |')i(srnt  tin-  loss  ol  iuidophilu-  |iro|H-irifs  iisu:ill\ 
pifsc'iit  in  inHlri;iri\c-  ti,ro\\rlis.  Miliui'  <iois  too  l;ir  in  denying  rlu- 
occuiitMU'f  ot  p!iiii;ir\  uppciidKuhir  (.aninoiiKis  ciuirclv  .  Lndoubted 
cases  of  rlu-  (.olloid  \;irKt\    with  ncuiniu-i'  lia\c  heen  reported. 

I  lu  siiKill  <;i()\\  rhs  aho\r  nunrioned  ^i\'c-  no  rlinioal  si^iis.  I  he 
laimi  L^iowtlis.  uiKiiK'Stioiiahh'  carcinoniatoiis,  liaxt-  lu-en  atteiidi-d  1>\ 
slight  pain  and  h\  tumor,  and  are  nodular  and  dense.  I'he  disco\'ei\  ot 
such  a  rumor  sug>2;ests  a  mali<j;nanc\'  of  rhe  <2;ur.  1  he  diagnosis  o\  its 
primary  seat  in  the  appendix  lias  usually  proved  impossible  clinically 
and  often  difficult  in  the  laboratory.  Sometimes,  at  operation  or 
autopsy,  rhe  cecum  antl  appendix  are  found  involved  (Fig.  374).  I  he 
pomr  of  origin  in  such  instances  cannot  always  be  made  out. 

Confusion  with  tuberculosis  is  possible  m  those  rare  instances  in 
which  the  tuberculous  process  is  limited  to  the  appendix.'-'  Lsuall\", 
however,  there  are  not  only  pulmonary,  but  also  peritoneal  lesions  to 
indicate  the  character  of  the  lesion.  Simple  inflammatory  thickening 
of  the  appendix  ma}'  simulate  a  neoplasm,  and  microscopic  examina- 
tions may  be  necessary  for  a  correct  diagnosis,  but  usually  the  uniform 
thickening  is  sufficiently  characteristic. 

Treatment, — The  vast  majority  are  removed  under  the  diagnosis  of 
appendicitis.  When  real  carcinomas  are  encountered  the}'  have  nearly 
always  extended  to  the  cecum,  and  the  treatment  is  the  same  as  for 
carcinoma  of  that  region. 

'  Deutsch.  Ztschr.  f.  Chir.,  1909,  cii,  251. 

-  Benoit,  Tuberculose  locale  chronique  de  la  region  ilcocecale,  Steinheil,  Paris,  1893. 


CHAPTER    XXXVI 

TUMORS  OF  THE  URINARY  ORGANS 

TUMORS    OF   THE   KIDNEYS 

General  Conception. — Until  recently  the  diagnosis  of  tumors  of  the 
kidney  has  been  very  uncertain,  especially  in  the  absence  of  a  micro- 
scopic examination.  Great  confusion  has  arisen  in  the  literature  from 
the  disposition  to  call  all  tumors  of  the  kidney  in  children  sarcomas 
and  all  tumors  in  people  of  middle  or  late  life  carcmomas.  Smce  the 
description  of  hypernephromas,  tumors  diagnosticated  as  carcinoma 
have  almost  entirely  disappeared  from  the  literature  (Garre).  For 
these  reasons  it  is  difficult  to  present  a  collective  picture  of  tumors  of 
the  kidne3\  Because  of  the  deep  position  of  the  kidnev,  the  physical 
signs  of  tumors  appear  relatively  late,  yet  diagnosis  is  possible  before 
this  time  from  the  urinary  changes.  The  determination  of  the  char- 
acter of  the  tumor  is  of  secondary  importance.  It  is,  therefore,  of 
advantage  to  consider,  first,  those  signs  which  permit  the  recognition 
of  the  presence  of  a  tumor,  and  second,  to  examine  evidence  which 
may  indicate  the  particular  type  of  tumor. 

Frequency. — Tumors  occur  with  greater  frequency  in  the  kidney  than 
in  any  other  solid  abdominal  organ,  at  least  where  tumors  become  a 
clinical  problem  (Kuster). 

Age. — As  pointed  out  by  v.  Bergmann,  the  solid  tumors  of  the  kidney 
occur  during  two  periods  of  life.  In  the  first  period,  from  the  first  to 
the  fifth  year,  embryonal  tumors  and  sarcomas  derived  from  them 
are  more  numerous  than  all  other  tumors.  In  640  cases  of  malignant 
tumors  of  the  kidne}^  reported  by  Kiister,^  128  occurred  before  the 
fifth  year.  The  fifth  and  sixth  decades  form  the  second  period,  during 
which  253  of  Kuster's  cases  occurred.  More  than  60  per  cent,  of  all 
cases  appeared  in  the  two  periods  mentioned  above. 

Etiology. — The  appearance  of  the  kidney  tumors  in  the  two  periods 
above  mentioned,  finds  a  partial  explanation  in  their  etiolog}'.  The 
majorit}^  of  the  cases  in  early  life  depend  upon  derangements  during 
development,  which  are  frequently  teratomatous.  The  frequent  and 
early    malignancy    of   these    tumors    lacks    a    satisfactory    explanation. 

^  Die  Chirurgie  der  Nieren,  Enke,  Stuttgart,  1902, 


riMOKs  or  Till:  KinxKYS  509 

The  <iit';ir  iiKii()rir\  ot  rumors  of  tin-  hitti  |)ciio(l  of  lite  undoubtedly 
arise  from  displaced  adrenal  tissue.  1  he  reason  why  these  displaced 
cells  do  not  hejj;in  a  rapid  growth  until  late  in  life  cannot  he  explained. 
Dormant  areas  of  such  cells  are  fre(iuentl\-  found  at  autops\  m  kidneys 
otherwise  normal.  In  some  instances  it  seems  probable  that  the  advent 
of  the  adrenal  substance  into  the  kidney  is  recent,  havinj^  been  trans- 
mitted from  the  adrenals  by  the  bloodvessels.  The  tumors  which  are 
not  dependent  upon  developmental  anomalies  have  no  obvious  etiology. 

A  histor\-  of  traumatism,  so  frequently  present  in  cases  elsewhere, 
can  rarel\-  be  elicited,  a  fact  easily  explained  by  the  secluded  position 
of  the  organ;  but  a  few  carcinomas  have  been  associated  with  stone 
of  the  kidnew  \\  hcthcr  or  not  the  congestion  incident  to  a  dislocation 
ma\-  contribute  to  the  production  of  tumors  is  doubtful. 

Clinical  Manifestations.  -The  important  clinical  signs  are  hematuria, 
pain,  and  tumor.  An  early  diagnosis  generall}'  depends  upon  a  proper 
anaKsis  of  these  symptoms.  Any  one  may  be  absent;  a  presumptive 
diagnosis  may  sometimes  be  made  without  the  physical  evidence  of 
tumor.  Signs  other  than  these  are  often  of  value  in  arriving  at  a 
conclusion. 

Hematuria. — Blood  in  the  urine  is  a  very  variable  symptom  in  renal 
tumors.  It  ma\-  appear  earh"  or  late;  it  may  be  plentiful,  slight,  or  be 
absent  during  the  entire  course  of  the  disease.  Authors  differ  widely 
in  the  estimation  of  the  frequency  of  hematuria.  All  are  agreed  that 
blood  appears  much  more  frequent!}'  in  the  renal  tumors  of  adults 
than  in  those  of  children.  Thus,  Kiister  found  hematuria  in  52  per 
cent,  of  adults  and  in  but  16  per  cent,  of  children.  Hemorrhage  is 
more  apt  to  occur  when  tumor  masses  project  into  the  pelvis  of  the 
kidney,  but  ma}-  take  place  when  the  tumor  lies  in  the  renal  parench\-ma 
or  even  without  the  capsule.  The  hemorrhage  in  these  instances  is 
ascribed  to  passive  h^'peremia  b}'  Israel.^  When  blood  is  present  in 
the  urine  it  is  necessary  to  determine  its  source,  and  the  cystoscope 
is  the  onl\'  reliable  agent  for  this  purpose.  When  it  is  of  renal  origin, 
ureteral  catheterization  will  determine  the  kidney  at  fault,  or  through 
the  c}-stoscope  bloody  urine  may  be  seen  to  spurt  from  one  ureter  and 
clear  urine  from  the  other.  For  this  purpose,  air-dilating  c\stoscopes 
are  preferable  to  water-dilating.  Bladder  hemorrhage  ma}-  co-exist 
with   renal  tumors  and  may  easily  cause  confusion. 

Pain. — Pain  in  kidne}-  tumors  is  present  in  but  20  per  cent,  of  cases, 
and  cannot  be  distinguished  b}-  its  location  from  pain  due  to  other 
causes.  It  is  frequentl}-  felt  in  the  epigastric  region,  and  when  due  to 
pelvic  distention   from   sudden  hemorrhage  or  from  ureteral  clots  may 

*  Chirur»ische  Klinik  der  Nierenkrankheiten,  Berlin,  Hirschwald.  1901. 


510  TUMORS  OF  THE  URINARY  ORGANS 

be  vesicular  or  perivesicular.  It  rarely  has  the  "focalized"  limitations 
of  stone.  The  cause  of  pain  is  variable.  When  hemorrhage  occurs  and 
coagula  form  in  the  ureter,  there  may  be  severe  colick}/  pains  simu- 
lating those  caused  by  stone.  In  the  absence  of  hemorrhage  there 
may  be  an  entire  absence  of  pain,  but  more  often  there  is  constant  or 
occasional  dull  pain.  Sharp  pains  may  exist  due  to  congestion.  When 
hemorrhage  is  profuse,  as  occurs  later  in  the  disease,  the  pain  may  be 
caused  by  sudden  stretching  of  the  pelvis  of  the  kidney  by  blood,  by 
the  hemorrhage  into  the  substance  of  the  tumor,  or  b}^  occlusion  of  the 
renal  veins.  In  tumors  which  invade  the  capsule,  particularly  carci- 
nomas, a  radiating  pain  may  be  caused  by  irritation  of  the  spinal  nerves. 
Pain  is  a  more  prominent  symptom  in  the  tumors  of  adult  life  than  in 
those  of  childhood.  Several  causes  of  pain  may  co-exist,  e.  g.,  tumor 
and  stone  or  chronic  interstitial  nephritis.  The  discovery  of  one  source 
of  pain  does  not  preclude  the  existence  of  another  cause. 

Tumors. — Tumor  is  not  palpable  in  every  case  at  the  time  when 
clinical  evidence  of  the  disease  is  present.  In  Albarran  and  Imbert's 
statistics^  but  59  per  cent,  gave  positive  palpatory  findmgs.  In  the 
renal  tumors  of  children,  tumor  is  present  in  a  much  larger  propor- 
tion, is  nearly  always  the  first  sign  present,  and  is  frequent!}^  the  only 
one.  Difficulty  arises  from  the  fact  that  conditions  other  than  neo- 
plasms cause  enlargement  of  the  kidney,  e.  g.,  tuberculosis,  suppura- 
tions, and  stone.  It  is  frequentlj^  necessary,  therefore,  to  rely  upon 
other  signs  for  a  diagnosis. 

Tumors  of  the  kidney  first  appear  in  the  renal  triangle.  When  they 
remain  within  the  kidney  capsule  they  are  free  from  the  liver  and  dia- 
phragm, and  do  not  move  with  these  organs.  When  of  considerable 
size  they  are  easily  detected  by  bimanual  or  even  abdominal  palpa- 
tion. Their  renal  origin  is  established  b}^  demonstrating  their  inde- 
pendence of  the  liver,  which  usually  can  be  done  easily  b}^  fixing  the 
tumor  between  the  two  hands  and  noticing  the  independent  respiratory 
excursions  of  the  liver.  Small  tumors,  particularly  when  located  at  the 
upper  pole,  may  escape  the  examining  finger.  They  may  be  reached 
by  deep  bimanual  palpation,  sometimes  with  and  sometimes  without 
a  general  anesthetic.  In  general,  the  loss  of  cooperation  in  an  anesthe- 
tized patient  more  than  counterbalances  the  advantage  of  the  greater 
muscular  relaxation. 

Examination  is  best  accomplished  by  careful  palpation  with  the 
patient  upon  the  back  and  the  finger  tips  of  one  hand  applied  to  the 
triangle  formed  by  the  twelfth  rib  and  the  lateral  border  of  the  quad- 
ratus  lumborum  muscle,  and  making  pressure  toward  the  kidney,  while 

^  Les  tumeurs  du  rein,  Masson,  Paris,  1903. 


TCMORS  OF   THE   KinMlYS  511 

rlu-  ;ilHl()niiii;il  IkiiuI  niakts  gentle  hin  tiini  |)i-(.ssiiic  into  the  itiial 
fossa.  Diiriiij!;  linp  respirations  at  rlu-  intcr\al  between  nv,piration 
and  expiration  is  rlu-  most  favoiahle  period.  When  the  tumor  itselt 
cannot  he  palpated  it  ma\  disphice  the  lower  jiole  ot  the  kidney  down- 
ward, makinti  it  more  readily  palpable  than  normal.  This  sij^n  advocated 
b)'  Israel  ^\ill  liktl\  pi()\-e  fallacious  in  all  hut  the  most  experienced 
hands. 

While  the  distinction  between  renal  and  hepatic  tumors  ma\  usually 
be  made  readih',  difficulties  sometimes  arise.  W'hen  the  tumor  is 
situated  at  the  upper  pole  and  has  broken  through  its  capsule  and  become 
adherent  to  the  liver  and  diaphragm,  it  ma\'  move  with  respiration, 
and  the  examining  hand  cannot  Hx  it.  Tumors  of  the  liver  ma\-  over- 
hang and  simulate  the  kidne}'.  The  hepatic  tumors  do  not  extend  to 
the  lumbar  triangle,  and  not  infrequently  the  kidney  can  be  palpated 
behind  the  liver  tumor.  The  continuit)'  of  liver  tumors  with  the  liver 
can  usuall\'  be  demonstrated  b\'  percussion,  since  the  colon  usuall\-  lies 
beneath  such  tumors  or  is  forced  down  by  them.  The  liver  tumors 
usually  have  associated  with  them  symptoms  which  are  of  value  in 
making  a  differentiation. 

Other  Signs  of  Kidney  Tumor. — Rise  of  temperature,  which  is  usually 
not  high,  may  be  the  hrst  sign  of  tumor.  Leukocytosis  is  not  great, 
and  is  chiefl}'  lymphocytic.  Varicocele,  particularly  when  occurring  on 
the  right  side  alone,  is  sometimes  a  valuable  sign.  It  is,  unfortunately, 
usually  late  in  the  course  of  the  disease.  It  is  due  to  obstruction  of 
the  spermatic  vein  secondary  to  thrombosis  of  the  renal  vein.  The 
extension  of  a  renal  thrombosis  to  the  vena  cava  ma}'  produce  edema 
of  the  legs  or  dilatation  of  the  superficial  veins  of  the  abdomen.  The 
first  evidence  of  renal  tumor  fhA'pernephroma)  ma)'  be  discovered  in  a 
metastatic  tumor,  particularl}'  of  the  long  bones  and  skull.  Cachexia 
and  anorexia  are  often  early  signs,  and  may  reach  a  marked  degree 
before  the  diagnosis  of  tumor  is  manifest.  The}'  may  co-exist  with 
other  manifestations  of  kidney  tumor. 

Diagnosis. — In  order  to  determine  that  a  tumor  of  the  kidne}'  is  neo- 
plastic a  variety  of  lesions  must  be  excluded.  Tuberculosis  may  cause 
a  kidney  to  present  itself  as  a  tumor,  but  the  condition  can  be  proved 
only  by  the  finding  of  tubercle  bacilli  in  the  urine.  The  .\-rays  deter- 
mine the  presence  of  a  stone  with  certaint}',  while  the  presence  of  a 
small  amount  of  blood  with  pain  on  movement  is  highly  presumptive 
of  neoplasm.  Pyonephrosis  is  distinguished  by  the  histor\-  and  b}'  the 
urinar}'  findings.  But  little  dependence  can  be  placed  on  the  presence 
of  fever,  since  a  raised  temperature  may  be  present  in  hypernephroma 
and  in  sarcoma.  The  presence  of  a  polynuclear  leukocytosis  of  con- 
siderable degree  would  indicate  a  suppurative  process. 


512  TUMORS  OF  THE  URINARY  ORGANS 

In  the  differentiation  of  the  various  lesions  a  study  of  the  urine  often 
gives  evidence  of  the  greatest  value.  In  tumor  in  the  intervals  when 
no  blood  is  present,  the  urine  may  be  perfectly  normal,  while  in  both 
stone  and  tuberculosis  leukocytes  are  present.  Tumor  is  often  simu- 
lated in  this  regard  by  the  so-called  essential  hematuria.  The  bladder 
is  often  the  source  of  blood  which  must  be  differentiated  from  that 
from  the  kidney.  The  cystoscope  gives  positive  evidence,  but  a  differ- 
entiation may  be  arrived  at  b}^  means  of  irrigation.  If  the  blood  is 
of  renal  origin,  the  irrigating  fluid  soon  runs  clear,  while  if  the  bladder 
is  the  source  a  small  amount  of  blood  is  constantly  present.  The  deter- 
mination of  which  kidney  is  at  fault  can  be  attained  only  by  ureteral 
catheterization  or  by  observing  the  spurting  of  the  urine  from  one  of 
the  papillae.  The  differentiation  of  those  cases  of  tumor  where  pain  is 
a  feature  from  the  renal  colic  of  stone,  may  often  be  made  positively 
b}^  means  of  the  ;t^-rays.  A  number  of  fallacies  may  appear.  Stone 
may  be  associated  with  tumor,  or  blood  coagula  of  tumors  may  give 
the  appearance  of  stone. 

The  functional  tests  of  the  kidneys  often  disclose  some  deviation  on 
the  part  of  the  affected  kidney,  and  at  the  same  time  permit  an  esti- 
mate of  the  functional  capacity  of  the  unaffected  kidney.  Unfortu- 
nately, the  lack  of  exactness  of  the  functional  tests  detracts  much  from 
their  practical  application. 

Often  the  utmost  exercise  of  clinical  acumen  will  succeed  only  in 
diagnosticating   a    lesion   of  the   kidney    requiring   surgical    treatment. 

Varieties. — After  diagnosis  of  a  tumor  of  the  kidney  has  been  made,  it 
is  necessar}^  to  determine  the  character  of  the  growth.  Microscopically, 
diagnosis  of  tumors  has  now  become  fairly  well  settled,  and  clinical 
pictures  corresponding  with  the  pathological  classification  may  be 
attempted.  It  must  be  admitted  that  a  cHnical  diagnosis  can  be  only 
tentative  vet}'  frequently  and  the  exact  variety  of  tumor  be  determined 
only  after  it  has  been  exposed.  Indeed,  in  some  instances  closer  study 
of  the  growths  in  the  laboratory  is  beset  with  uncertainty. 

Hypernephromas.^ — These  are  tumors  derived  from  the  suprarenal 
gland,  and  resemble  more  or  less  its  structure.  They  are  discussed  in 
connection  with  the  kidney  because  the  vast  majority  of  hypernephromas 
are  found  in  that  organ.  They  are  also  found,  it  may  be  said  in  pass- 
ing, in  the  ovaries,  testicles,  broad  ligaments,  and  elsewhere.  It  belongs 
to  the  credit  of  Grawitz^  to  have  properly  worked  out  the  nature  and 
origin  of  these  tumors,  which  before  he  presented  the  results  of  his  work 
were  variously  regarded  as  lipomas,  adenomas,  adenocarcinomas,  and, 
when  large  and  invading  the  surrounding  tissue,  as  sarcomas. 

1  F.  J.  Hall,  Arch.  Int.  Med.,  1908,  ii,  355. 

-  Virchow's  Arch.  f.  path.  Anat.,  1883,  xciii,  39;  Arch.  f.  klin.  Chin,  1884,  xxx,  824. 


ri  MORS  oi   'nil.  Kih\i:Ys  :a:\ 

I  lu-  Wdiil  In  |>ri  lu  pliioiiKi  fxpii-ssfs  Nfiy  \\cll  the  histo^ciusis  ot 
these  rumors.  (  )|>ini()n  is  still  cii\uletl  as  to  then  natiiie.  Some  \v(julcl 
chissit)'  riu-ni  as  laicinonias,  otiurs  as  eiidothehomas,  and  still  others 
as  saiconias.  All  an-  aiiieid,  hoNseN'er,  that  the\'  are  (len\e(l  from  niis- 
placecl  ailimal  tissiu-.  It  is  useless  and  lonlusni^  to  attinipt  to  toice 
tinnors  so  spceihc  ui  stiuctuic-  as  those  diiixcd  troin  adiiiial  tissue 
nito  an\    ol   tin-  jiicat  i^ioups  ot   tumors. 

ti^-  37S 


,V. 


4      '/ 


M^ 


■^> 


^   ■"■^  ^: 


Kncapsuiated  h\pernephr()nia  z  mm.  m  diameter. 


.-\q). 


1  he\"  form  the  most  common  tumor  of  the  kidney,  bem<i  more  than 
ten  times  as  frequent  as  carcinomas,  sarcomas,  or  malignant  adenomas. 
If  apparenth'  quiescent  encapsulated  tumors  of  small  size  are  counted, 
the  excess  is  even  greater. 

.M.\CR()Scopic  Appe.-vr.ance. — Hypernephromas  may  he  too  small  to 
be  distinguished  with  the  unaided  eye,  or  they  may  appear  as  small, 
vello\vish-gra\-  dots.  When  larger,  the  yellow  color  is  often  more  marked. 
Not  infrequenth'  they  are  completely  encapsulated,  and  a  spontaneous 
cure  may  then  be  said  to  have  taken  place  (Figs.  }J^  and  376).  The 
tumors  that  go  on   to  active  growth   usually  retain  a  capsule  and  dis- 


514 


TUMORS  OF  THE  URINARY  ORGANS 


place  the  surrounding  tissue.  As  the  tumors  grow,  however,  the  capsule 
is  perforated  and  nodules  are  formed  in  the  surrounding  tissues.  The 
extension  usually  is  into  the  renal  tissue  (Fig.  377)  or  into  the  veins, 
but  later  the  perirenal  tissue  likewise  becomes  invaded.  The  new  nodules 
form  capsules  which  in  turn  may  be  invaded  and  new  tumors  formed. 
It  is  but  rarely  that  the  cells  extend  diffusely  into  the  tissue.  These 
tumors  have  a  peculiar  predilection  for  the  veins.     Prolongations  may 

Fig.  376 


Encapsulated  hypernephroma. 

extend  into  the  renal  vein,  the  cava,  or  even  into  the  right  heart.  Hyper- 
nephromas are  usually  yellowish,  and  for  this  reason  were  formerly 
confused  with  lipomas,  but  they  are  often  reddish  from  hemorrhage 
or  grayish  when  degeneration  is  present  or  is  impending. 

Microscopic  Appearance. — Two  types  of  cell  arrangement  may 
be  made  out — the  papillary  and  the  alveolar.  In  the  former  there  are 
finger-hke  projections  which  consist  of  vessels  with  cells  closely  arranged 
about  them.  This  form  is  particular!}^  apt  to  occur  where  there  is  a 
disposition  to  cyst  formation  (Fig.  378).  In  the  alveolar  type  there 
are  definite  connective-tissue  alveoli  filled  with  cells  (Fig.  379).  The 
alveoli    contain    vessels    about  which    the    cells    are    arranged    similarly 


TiWKJRs  or  77//;  A//).\7;>'.S 


515 


to  rlu-  anunm  iiuiit  ahoiii  ilu-  \i-ssc-ls  in  the  p;ipill;ii\'  r\  pc-.  \  v\\  iix- 
Hiunrh  rlu-  ;il\t.()l;ii  ;iiul  p;i|>ill;ii\  \;iiurics  ;iic  inti  rmixtcl.  In  ;i  general 
\\;i\  rlu-  ;il\t-<)lar  iirianjifiiu-nr  is  more  apt  to  pietloiiiiiiate  in  the  lai{i;er, 
nu)rc-  lapitih  <:;r()\vin^  tumors,  rlu)ii^;h  this  is  suliject  tf)  many  excep- 
tions. I  lu-  ilosc  associarioii  ot  cells  and  \  essels  accounts  tor  the  per- 
sisreiu'c-   ot    mam     wnrtis    m    classit\inji,    tlu-m    \sirli    the    (lulorlu-liomas 

V\c,.  377 


Hvpern   phroma  with  secondar\-  nodult-s  m  the  substance  ot  the  kidney. 


or  the  ah'eolar  sarcomas.  The  cells  themselves  turnish  the  distinmiish- 
ing  features.  They  are  large  and  otten  pohhedral,  though  they  may, 
particularly  in  the  papillary  type,  closely  resemble  adrenal  cells.  1  he 
large  cells  are  made  up  of  granular  protoplasm,  which  stains  poorly. 
The  nuclei  are  also  poorl\'  staining,  frequently  fragmentary,  and  rarely 
show  mitotic  tigures.  The  protoplasmic  masses  may  appear  confluent, 
resembling  in   this  regard   the  s\nc\tial  cells  ot   the  deciduomas.      1  he 


516 


TUMORS  OF  THE  URINARY  ORGANS 
Fig.  378 


J^  0    ®" 


F^  ^*  @l 


<Sm     Y-^      "  - 


5,    1>K'V'>^    *^^' 


^  a^H  aft  &,  a       w  a      „■""/'    i      5>  ^7  w  ^ 


€S: 


<? 


,& 


is 


©.  ?  *  **' 


i5  ^ 


1^  ,.V      M.t.-"    ,*      , 


Hypernephroma  (papillary  cyst-adenoma 
Fig.  379 


iB^''- 

4 

■■I 

>^i, 

i*^ 
%,  & 

6 

*  -0' 

^ 

V**  .  e   \  «. 


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V=^ 


>-i<^' 


is     If  J  a 


«Si. 


\is,:\     :gv- 


is-   '  'J"/'/' 
Hypernephroma  of  kidney. 


riMfjRs  or  rill:  kidxeys  517 

(.■|uinisti\  ot  tlusi-  tumois  is  s;iul  In  Ciottoii'  to  he  dia^nosru .  Ilr 
srarcs  tluit  a  \\;itn\  i-\ri;u-t  of  these  tumors  will  eli;iiii;(  uiuDoked  si;inh 
iiUo  lactose  A\\(\  cUxtiose,  ;iiul  that  it  uill  tleeolon/i  hoiled  stanh  siaiiu d 
with  lochiu-.      Ilall  lias  conHniu-d   these  Hndin^s. 

Diagnosis.  I  in-  tact  that  a  tumor  ot  x\^v  ki{hu-\'  oeeuis  m  an  adult 
IS  iisiiall)  sufHcieiit  to  exclude  eiiihryonias,  and  m  tlu  maj()rit\  of  cases 
such  a  tumoi  will  he  a  hyperiiephroiiia.  These  }i,i()\\ths  show  a  definite 
tumor,  and  tluir  soft  consistency  can  usually  he  madt  out  on  clinical 
examination.  Ileni()rrha<i;e  is  often  eailv'  and  considii  ahle.  I  lu  slo\v- 
growth  nia\  help  to  diffeientiate  them  from  carcinoma,  i'malh,  hone 
metastasis  is  almost  certainly  diagnostic  of  hypernephroma.  When 
exposed  at  operation,  the  color  and  consistency  usualU  distinguish 
them  from  carcinoma.  Rarely  are  carcinomas  so  soft,  and  rhe\'  are 
uniformly  grayish  white,  while  hypernephromas  are  almost  sure  to  present 
characteristic  mottling  in  some  part.  Microscopically,  it  is  the  form 
of  the  cells  and  their  close  arrangement  ahout  the  vessels  which  are 
distinctive.  Ihe  malignant  c\'stadenomas  cause  the  greatest  confusion, 
and  the  form  of  the  cells  must  be  relied  upon  to  form  the  difFerentiation. 
Often  the  clinical  course  of  the  growth  ma^'  aid  in  diagnosis.  1  he 
absence  of  a  capsule  may  help  to  identify  epithelial  tumors.  The  sar- 
comas are  usually  homogeneous  on  section  and  their  cell  forms  are 
distinctive. 

Metastases. — Hypernephromas  tend  to  remain  localized  for  a  long 
period,  but  often  early  invade  the  veins  and  give  rise  to  distant  metas- 
tases.- The  bones  and  the  lungs  are  the  most  frequent  sites  of  metastases, 
though  the  lymph  glands  are  occasionall\'  invaded.  Metastases  in  some 
distant  region  ma}'  be  the  first  symptom  of  a  kidne\'  h\pernephroma. 

Mixed  Tumors. — The  occurrence  of  several  mesodermal  tissues  in 
a  single  kidney  tumor  which  appears  in  earl}'  life  or  even  before  birth 
indicates  a  congenital  origin.  The  complex  structure  of  these  tumors, 
which  is  exclusiveh'  mesodermal,  led  Wilms-'  to  assume  their  deriva- 
tion from  an  earh'  mesodermal  rest  rather  than  from  cells  displaced 
at  a  later  period  of  development.  One  explanation  of  their  origin  is 
from  the  connective  tissue  of  the  Wolffian  bodies,^  and  another  view= 
IS   that  the  anlage  of  the  kidney  itself  is  the  source  of  these   tumors. 

Macroscopic  Appearance. — These  tumors  usualh-  form  globular 
tumors,  often  of  enormous  size,  even  rivalling  in  weight  the  little  patients 

'  Jour.  Anier.  Med.  Assoc,  1903,  .\1,  91. 

-  Bierring  and  Albert,  Jour.  Amer.  Med.  Assoc,  1904,  xliii,  234. 
•*  Die  Ahschgeschwiilste  der  Xiere,  Georgi,  Leipzig,  1899. 

■*  Birch-Hirschfeld,  Beitr.  z.  path.  Anat.,  1898,  xxiv,  343;    Ribbert,  \'irclio\v's  Arch.  f. 
path.  Anar.,  1892,  cx.xx,  249. 
^  Ikisse,  \'irchow's  Arch.  f.  path.  Anaf.,  1899,  civii,  346. 


518  TUMORS  OF  THE  URINARY  ORGANS 

they  afflict.  They  are  rarely  markedly  bosselated,  but  when  some  areas 
grow  with  greater  rapidity,  nodulations  of  the  surface  may  occur.  On 
section,  they  are  pinkish  or  grayish.  Cysts  containing  clear  fluid  may 
be  present.     Necrotic  or  hemorrhagic  areas  are  sometimes  noted. 

Microscopic  Appearance. — The  usual  picture  is  that  of  a  glandular 
organ  with  an  abundance  of  interglandular  young  connective  tissue. 
Their  structure  seems  to  warrant  the  designation  applied  to  them — 
adenosarcoma  (Fig.  380) — a  picture  now  generally  recognized  as  evidence 
of  a  developmental  origin.  In  large  or  rapidly  growing  tumors  not 
infrequentl}^  all  trace  of  gland  structure  is  lost  and  a  sarcoma  is  simu- 
lated.     In   other   instances    the   glandular    proliferation   may   be   more 

Fig.  380 


&««» 


i^V^ ,  ..    .     ._ „ ..„    ^       „.        „ 


if"™* 


tif^' 


Mixed  tumor  of  the  kidney  (so-called  adenosarcoma). 

prominent  and  cystic,  or  papillary  cystic  areas  may  be  seen.  Not  infre- 
quently, these  tumors  are  more  complex,  containing  cartilage  and 
particularly  striated  muscle  fibers.  It  is  often  difficult  to  distinguish 
between  these  and  certain  types  of  hypernephromas,  and  frequently 
the  macroscopic  appearance  and  clinical  course  must  be  called  to  the 
aid  of  the  microscope  before  an  approximate  opinion  can  be  formed. 
These  facts  make  it  seem  likely  that  the  small  adenomas  and  cyst- 
adenomas,  often  accidentall}^  discovered,  are  congenital  rests. 

Diagnosis. — Mixed  tumors  nearly  always  present  a  tumor  on  palpa- 
tion, and  usually  the  bulging  of  the  kidne}^  region  is  the  first  evidence 


Tl  MORS  or    Till.    KIDM.ys  ol9 

ot  tlu-  piisiiui-  ol  ilis(.;isc.  I*;iin  is  iisu;ill\  ahsciii  ;iiul  hi  nionha^e  is 
rare.  Metastasis  is  lare,  l>iii  ma\  take  phu*-  m  an\  paniicliN  niatous 
orj^an.  I  lu  \  aw  tiiinors  of  iail\  lite  ami  lre(iiunfly  mulei^o  rapid 
cleNelopim  nt,  wliuli  tact  alone  is  diajiiiostu-.  I  he  only  disease  likel\- 
to  he  niistakiii   tor  inixcil   luniois  is  h\  (li()ne|ihrosis. 

I  ki:a'I"MHNI'.  These  tiimois  are  not  adherent,  and  unless  very  lar^ie 
rluii  removal  nia\  he  arteiiipricl.  Recunence  is  tie()uent  and  the 
opeiati\e  mortality  is  hi^h. 

Sarcoma.  These  rumors  are  rare.  I  he\  may  arise  either  trom  the 
capsule  or  trom  the  mtercanahculai"  tihrous  tissue,  and  may  therefore 
appear  primarih  upon  the  surface  or  within  the  kidne\  .  I  he\'  Unuy 
nodular  growths,  hut  ai'e  usually  not  encapsulated.  I  he  \anous  cell 
t\pes  are  found,  and  the  consistency  and  the  rate  of  growth  correspond 
in  a  general  wa\  to  the  usual  manifestations  of  the  type.  The  general 
susceptihilit\  of  kidne\-  tumors  to  secondary  degeneration  is  shared 
h\'  these  rumors.  Man\'  of  the  cases  recorded  occurred  m  early  life, 
and  often  sufficient  care  has  not  been  used  to  differentiate  the  mi.xed 
tumors.  Those  reported  as  m3'xosarcomas  or  chondrosarcomas  prob- 
abU'  belong  to  the  hypernephromas.  The  cystosaicomas  of  children, 
on  account  of  the  earh"  age  at  which  they  appear  and  their  general 
course,  are  probabh'  developed  from  embryonal  tumors. 

Carcinoma. — The  usual  form  is  the  adenocarcinoma,  but  the  simple 
carcinoma  is  observed  with  nearly  equal  frequency.  A  circumscribed 
tA"pe  differing  histologically  in  no  wa^'  from  the  adenocarcinoma  has 
been  described.  It  tends  in  some  instances  to  form  papilloc\-stomas. 
In  all  these  tA'pes  except  the  last  mentioned  there  is  a  general  disposi- 
tion to  invade  the  surrounding  tissue,  the  fatty  capsule,  and  particularly 
the  hmph  glands  at  the  hilum,  and  to  compress  the  spermatic  vein. 
This  gives  rise  earlv  to  the  formation  of  varicocele,  frequently  before 
the  presence  of  kidney-  tumor  is  suspected.  There  is  usually  renal 
pain,  which  is  often  severe,  and  frequentl\-  hemorrhage.  The  hemor- 
rhage is  persistent,  and,  while  varying  in  intensity,  ma}'  be  very  great. 
Ihese  tumors  occur  mainly  in  adult  life,  and  the  diffuse  character 
of  their  growth  and  their  density  when  first  seen  permits  a  diagnosis. 
On  section,  the\'  are  prone  to  show  secondary-  degenerative  changes 
common  to  other  malignant  disease  of  the  kidney". 

Lipomas. — Lipomas  of  the  kidney  ma)'  occur  as  masses  of  fat  which 
embed  the  entire  kidney  and  which  are  attached  to  it  b\'  fatty  septa 
or  as  small  encapsulated  nodular  masses  of  fat  occurring  immediately 
under  the  capsule,  rarely  in  the  interior  of  the  kidney.  1"  rom  their 
size  the\"  cause  compression  and  destruction  of  the  kidney  substance. 
Occasionall\  ,  a  pelvis  dilated  from  other  diseases  may  HI!  with  fat. 
Lipomas  rareh"  give  rise  to  clinical  symptoms,  and  when  the\'  do  it  is 


520 


TUMORS  OF  THE  URINARY  ORGANS 


their  size  alone  that  makes  them  of  importance.  At  operation  the 
diagnosis  is  easy  save  that  a  kidney  atrophied  from  disease  and  sur- 
rounded   by    a   hypertrophied    fatty   capsule   may   appear   as   a   lipoma 

Fig.  381 


Congenital  cystic  kidney. 

during  the  course  of  the  operation.     Removal  of  the  mass  together  with 
the  kidney  is  usually  practicable. 

Fibromas.— Tumors    composed    of    fibrous    tissue    alone    are    usually 
small  tumors  within  the    kidney  which   are  discovered  accidentally   in 


T( MORS  or  rill-:  Kih\i:ys  521 

postmortem  t\;imm;ii  ions.  In  roii|iHut  ion  uith  otiui  tissue,  iisu;ill\ 
nnxoid  or  museiihii,  l;ii{i,i-  tumors  ;ire  soiiietinies  formed.  In  eiit;im 
e\sru'  eonditions  m  uliieli  rluie  i.s  a  proliferation  of  fihroiis  tissue, 
it  is  pioliahle  that  the  growth  heloiijis  to  the  mi.xed  tumors. 

Cysts.  C\)N(;i:nii.\i,  Cast's.  In  this  toiulition  the  ki(lne\  is  beset 
with  a  multitude  of  small  cysts  raii^in^,  from  microscopic  si/e  to  the 
si/.e  ot  a  walnut  (Fiji.  3H1).  The  condition  is  nearly  always  bilateral. 
\\  bile  I  \  iilenth  conf2;enital  m  origin,  the\  usually  do  not  manifest  them- 
selves until  muKlIe  life,  thou<i,h  the\  are  fie(|uenrl\  found  in  stillborn 
children.  I  he  kidne\  fre(iuentl\'  attains  an  enormous  size,  as  much  as 
sixteen  inches  in  length.  Ihe  cysts  are  lined  with  a  low.  Hat  epithelium 
resting  on  a  connectixe-tissue  base.  I  he  epithelium  ma\  show  active 
proliferation  or  may  be  entirely  absent.  I  he  cyst  contains  a  clear 
fluid,  which  ma\  be  tinged  with  blood  or  may  be  blood  red.  I  he  urinif- 
erous  tubules  between  the  cysts  retain  their  mtegrit)'  for  a  long  time. 
These  c\sts  are,  according  to  one  explanation,  due  to  congenital  mal- 
formation, or,  according  to  the  other,  to  inflammatory  occlusion  of  the 
developed  tubules,  the  contents  being  urine  modified  by  the  prolonged 
retention. 

Clinicall)',  these  tumors  appear  as  enlargements  of  either  one  or 
both  kidne\s,  and  the  diagnosis  is  simply  of  abdominal  tumor.  Fre- 
(luenth',  evidence  of  renal  insufficienc\'  is  present  before  the  tumor  is 
discovered.  The  reniform  enlargement,  particular!)  if  bilateral  and  at 
middle  life,  is  sufficiently  characteristic  for  diagnosis.  If  unilateral, 
operative  removal  has  been  practised. 

Acquired  Cysts. — The  discovery  in  the  course  of  postmortem  work 
of  single  cysts  ranging  in  size  from  a  pea  to  an  apple  is  a  common  occur- 
rence. The\'  project  as  a  hemisphere  beyond  the  surface  ot  the  kidne\' 
and  contain  a  clear  fluid.  They  have  no  clinical  histor\-,  but  are  fre- 
quentlv  associated  with  contracted  kidney.  Should  such  a  cyst  be 
discovered  in  the  course  of  an  operation  for  some  other  lesion,  it  may 
be  punctured. 

Prognosis.  All  forms  of  malignant  kidney  tumors  offer  prospects 
of  cure  in  proportion  to  the  earliness  at  which  the  tumor  is  remo\ed. 
They  offer  favorable  anatomical  conditions  for  a  cure.  The  organ 
possesses  its  own  capsule,  is  relatively  poor  in  lymphatics,  and  in  addi- 
tion is  surrounded  by  a  protecting  layer  of  fatty  tissue.  The  removal 
of  a  tumor,  whether  it  is  encapsulated  or  not.  should  be  complete  before 
the  invasion  of  the  kidney  capsule.  Unfortunately,  such  a  possibility 
is  offset  b\"  the  disposition  of  the  most  frequent  t\pe  of  kidney  tumor, 
hypernephroma,  to  invade  the  renal  vein.  Metastasis  may  rake  place 
in  this  way  while  the  tumors  are  still  small.  The  unfavorable  condi- 
tions are  increased   b\'   the  fact  that  from   the  hidden   position   of   the 


522  TUMORS  OF  THE  URINARY  ORGANS 

kidney  the  recognition  of  renal  tumors  must  be  relativel}^  late.  The 
h3^pernephromas  afford  the  best  prognosis.  The  operative  prognosis 
is  about  75  per  cent,  of  recoveries.  Ill  results  from  operation  come 
from  shock,  hemorrhage,  and  infection.  The  percentage  of  recoveries 
after  operation  has  not  been  determmed  with  serviceable  accuracy. 

Treatment. — The  recognition  of  a  kidney  tumor,  with  the  exception 
of  the  cystic  type,  carries  with  it  the  indication  for  removal.  Before 
removal  is  undertaken  the  presence  and  functional  capacity  of  the 
opposite  kidney  should  be  determined.  This  may  be  done  by  cathe- 
terization, segregation,  or  operative  exploration.  The  tumors  may  be 
approached  from  the  lumbar  region  or  transperitoneally.  The  former 
route  mav  be  selected  for  small,  easily  removable  kidneys.  The  danger 
of  infection  is  less.  The  transperitoneal  route  is  suitable  for  all  sizes  of 
tumors,  and  gives  better  access  to  the  vessels,  which  is  a  matter  of 
importance  when  they  are  fragile  or  the  seat  of  tumor  extensions.  This 
method  is  preferred  by  most  operators  when  a  suppurative  process  can 
be  positively  excluded. 


TUMORS    OF   THE   ADRENAL 

The  tumors  of  this  organ  are  rare.  A  large  variety  has  been  described, 
but  when  the  confusion  surrounding  the  pathogenesis  of  tumors  of 
the  kidney  originating  from  adrenal  rests  is  remembered,  it  is  not  diffi- 
cult to  comprehend  the  source  of  the  confusion  when  the  tumors  of  the 
adrenal  itself  are  concerned.  There  is  no  uniformity  of  nomenclature 
even  among  those  who  accept  the  modern  view  as  to  the  nature  of 
the  tumors  which  spring  from  the  suprarenal  capsule.  It  is  question- 
able if  a  definite  designation  is  needed.  The  term  hypernephroma, 
obviously  especially  appropriate  to  primary  tumors  of  this  organ,  has 
been  applied  to  the  more  common  aberrant  tumors,  and  if  the  same 
term  were  to  be  used  to  designate  all  tumors  of  the  adrenal  an  awkward 
qualifying  phrase  would  be  required.  It  seems  desirable,  therefore, 
to  dispense  with  a  single  general  term  for  these  tumors. 

The  adrenal  tissue  in  its  native  site  undergoes  the  same  neoplastic 
changes  as  when  displaced  in  the  kidney.  Small  nodules,  either  single 
or  multiple,  formed  of  little  changed  adrenal  cells  have  been  observed, 
and  the  term  adenoma  may  be  applied  to  them  without  offence.  When 
they  develop  rapidly  and  exhibit  malignant  tendencies,  they  correspond 
to  the  hypernephromas,  and  the  attempt  to  classify  these  as  either  sar- 
comas or  carcinomas  is  as  objectionable  as  in  similar  tumors  occurring 
in  the  kidneys. 

The  macroscopic  appearance  is  the  same,   usually  yellowish,  except 


ri  MORS  or  rill.  .ihki:\.ii.  52:! 

wluii  iindciiioinj;  cUmiu  r;iri\f  oi  luciotii-  ilianms.  I  lu\'  iirc  e\'eii 
iiioif  tlisposed  to  luMioi  I  h;iii,K-  iiihlriarioii  ih;iii  tin  simihir  niuil  miiiois, 
ami  c\sr  toniKirion  is  common.  I  In-  micioscopic  sri  iicrinf  :ipp;iicnrl\ 
varies  less  hom  rlu-  adrenal  r\  pc;  possil)l\  this  is  (Iik-  to  statistical 
firois  liom  tlu-  tact  that  i-ontusion  with  rcratoul  tiimois  has  heen  less 
fie(iiient  than  m  the  kidney.  I  aken  all  together,  the\'  are  infrecjuent 
tumors.  Rolleston  and  Marks'  were  able  to  collect  hut  26  cases,  thoiijih 
Israel"  has  had  a  personal  experience  of  9  cases. 

Symptoms  and  Clinical  Course.  liu-  de\elo|-»nunr  of  tlust-  tumors 
in  the  adrenal  dilters  but  little  from  the  similar  tumors  in  the  kidne\'. 
There  is  the  same  mode  of  extension,  the  same  predilection  for  exten- 
sion into  the  surioundin<i  tissue  and  for  distant  metastasis.  Thev 
tend  more  earl\  to  escape  from  their  capsule,  with  the  consequent  earl\' 
unasion  ol  the  surrounding  tissue.  Because  of  this,  pain  from  invasion 
ot  the  nerves  is  sometimes  early,  and  according  to  Israel  the\'  are  more 
often  accompanied  by  rise  of  temperature,  due,  my  experience  would 
lead  me  to  believe,  to  the  greater  tendency  to  degenerative  changes. 
Hematuria  due  to  compression  of  the  veins  is  frequent.  The  s\'mptoms 
of  disturbed  adrenal  function  are  sometimes  added — not  onlv  great 
weakness  and  gastric  disturbance,  but  in  rare  instances  bronzing  of 
the  skin. 

Diagnosis."  Israel'  has  discussed  the  clinical  diagnosis  of  these  tumors 
with  great  acumen.  When  no  tumor  is  palpable,  but  there  is  pain  and 
paresthesia  of  the  lumbar  plexus  with  hematuria,  and  stone  of  the 
kidne\'  can  be  excluded,  he  regards  the  diagnosis  as  probable.  An\- 
increase  in  temperature  adds  to  the  probabilit}'  of  its  adrenal  location. 
The  very  absence  of  a  palpable  tumor,  too,  speaks  for  the  adrenal  lesion, 
for  when  renal  tumors  cause  pain  they  usualh'  have  attained  such  a 
size  that  they  are  easily  palpable.  When  a  palpable  tumor  is  present 
it  may  be  possible  to  feel  the  normal  kidne\'  below  and  lateral  to  it; 
when  this  is  not  possible  the  location  of  the  tumor  ma\'  be  distinc- 
tive. Renal  tumors  appear  at  the  costal  margin  between  the  ninth 
and  eleventh  ribs,  while  adrenal  tumors  appear  at  the  eighth  or  even 
the  seventh.  When  the  adrenal  tumor  has  become  amalgamated  with 
the  kidney  the  first  appearance  of  the  tumor  at  the  eighth  rib  and  a 
rise  of  temperature  suggests  a  primary  adrenal  tumor.  If  in  either 
of  these  instances  a  bronzing  of  the  skin  is  present,  the  diagnosis  is 
facilitated,  but  it  must  be  remembered  that  a  renal  tumor  maA'  com- 
press the  common  duct  with  a  consequent  jaundice  that  ma\'  be 
confusing. 

*  Amer.  Jour.  Med.  Sci.,  1898,  cxvi,  383. 

-  Deutsch.  med.  Woch.,  1905,  xxxi,  1745.  ''  Loc.  cit. 


524  TUMORS  OF  THE  URINJRY  ORG  J  AS 

Treatment. — Owing  to  the  disposition  of  these  tumors  to  early  inva- 
sion, and  the  difficult}'  in  making  an  earl}'  diagnosis,  the\'  are  not  often 
amenahle  to  surgical  mterference. 


TUMORS    OF   THE   PROSTATE 

Tumors  of  the  prostate  gland  have  m  the  past  been  considered  as 
rarities,  but  more  recent  studies  have  demonstrated  that  many  tumors 
which  affect  it  have  been  misinterpreted  or  overlooked.  With  the 
recent  advances  in  surgery  of  the  prostate,  the  importance  of  recog- 
nizing earlv  the  tumors  to  which  it  is  liable  has  been  emphasized.  Of 
these,  carcinomas  are  by  far  the  most  common,  sarcomas  much  less 
so,  and  other  varieties  may  still  be  considered  distinctly  rare. 

Carcinomas. — According  to  Young,^  lo  per  cent,  of  all  enlarged  pros- 
tates are  carcinomatous.  While  this  is  probably  a  larger  proportion 
than  obtains  in  the  experience  of  most  surgeons,  owing  to  the  fact  that 
the  severer  types  of  all  diseases  tend  to  gravitate  to  specialists  of  marked 
distinction,  vet  Young's  studies  seem  to  emphasize  the  fact  that  man\' 
cases  of  carcinomatous  prostates  go  unrecognized. 

Etiology. — Aside  from  the  fact  that  apparently  man}'  prostates  which 
are  carcinomatous  have  previously  been  the  seat  of  chronic  enlarge- 
ment, nothing  is  known  respecting  their  genesis.  The  glandular  hyper- 
troph}'  associated  with  the  inflammator}-  processes  so  frequenth'  seen 
in  chronic  prostatic  disease  is  sufficient  to  account  for  the  develop- 
ment of  malignancy.  Other  factors,  such  as  venereal  disease,  have  not 
been  estabHshed.  Carcinomas  occur  most  frequenth'  between  fifty  and 
seventy  years  of  age  and  rarely  under  forty. 

Pathology. — Gross  Appearance. — Thecarcinomatous  prostate  is  nearh' 
always  enlarged,  although  in  a  few  instances  it  has  been  found  normal 
in  size  or  smaller.  In  some  cases  a  single  lobe  is  affected,  but  usuall}"  the 
entire  gland  is  more  or  less  involved.  The  effect  on  the  general  contour 
of  the  gland  is  variable.  Early  in  the  disease,  when  the  area  involved 
is  small,  simple  nodulations  covered  b}^  normal  prostatic  tissue  ma}' 
be  present,  but  at  a  later  stage  the  entire  gland  is  nodulated.  The 
effect  on  the  consistency  of  the  organ  is  always  the  production  of  the 
density  characteristic  of  carcinomas.  The  disease  respects  the  capsule 
for  a  long  time. 

The  first  point  of  invasion  is  usuall}'  the  triangle  between  the  seminal 
vesicles,  and  thence  into  the  bladder.  In  many  of  the  recorded  cases, 
when  the  diagnosis  was    made  late  in  the    course  of  the  disease  or  at 

^  Johns  Hopkins  Hosp.  Rep.,  1906,  xiv,  485. 


77  .i/oA'.s  oi   rill.  I'Rosr  III-:  :,_'.-, 

.iiit()[)s\  ,  It  w.is  not  ;il\\;i\s  tk;ii  \slutlur  tlu-  disease-  oi  i;;iiiarttl  in  rlu- 
piosrati-  OI  \\\  tlu-  Maddfi,  and  thus  tin-  (|iu-sti()n  ot  t-\rrnsion  has  ht-t-n 
(-■onliist-d. 

1  hi-  >iU(.stion  ol  l\niphati(.-  i-\ti-nsion,  hki-wist-,  has  hccii  contused 
l^fcaiisf  rhi-  sratisrus  do  not  al\\a\s  lonsuUi  the  staj^e  of  the  disease. 
In  \\()IH"s  staristiis,'  in  all  hut  20  pii  cent,  tin-  I\  in|ih  j^lands  were 
iinaded.  In  ^  ounji's  sriidies  this  rate  did  nor  ohtain.  The  foinier 
wiitei'  compiled  his  sratistics  from  postmortem  studies,  while  the  lattei 
ai"i"i\ed  at  his  opinion  tiom  clinical  srud\  .  it  ma\'  he  regarded  as  estab- 
lished that  d  the  ilisease  is  recogm/ed  early,  the  probability  is  that 
the  lymph  glands  are  not  invaded.  When  lymphatic  e.xtension  does 
occur  the  iliac  glands  are  the  Hrst  to  become  involved,  followed  b\- 
rile  inguinal,  sacral,  and  Imiihai  in  the  order  named.  The  periprosraric 
connecriNe  tissue  in  late  cases  may  be  e.\tensivel\-  invaded. 

lM)rmerly  the  diagnosis  was  not  made  in  many  instances  until  such 
invasion  was  noted.  I  his  accounts  for  the  greater  frequency  of  this 
complication  in  the  early  reported  cases.  On  section,  the  usual  puncti- 
torm  appearance  of  carcinoma  is  apparent,  but  the  difficult\-  of  recog- 
nition ot  the  gross  specimen  is  great  because  the  glandular  proliferation 
of  the  simple  hypertrophied  gland  may  closeK'  resemble  the  malignant 
growth.  When  fatt\-  degeneration  of  the  cells  has  taken  place  their 
yellow  color  makes  them  more  easily-  distinguishable  from  the  glandular 
hypertrophies. 

Distant  metastases  occur  with  surprising  frequency  in  bone.  Thev 
are  usually  multiple,  but  ma\'  be  single.  Metastases  in  the  liver  and 
the  lung  follow  in  order  of  frequence 

Microscopic  Appe.^rance. —  In  general,  two  histological  types  of 
piostatic  carcinomas  may  be  distinguished — the  glandular  and  the 
simple.  The  glandular  type  retains  some  resemblance  to  the  normal 
glands  or  to  the  hyperplastic  glands  of  prostatic  hypertroph\'.  The 
earliest  changes  consist  in  the  formation  of  papillar\'  projections  into 
the  lumen  of  the  glands.  These  may  form  complete  septa  across  the 
gland,  or  may  nearly  or  completely  fill  the  lumen.  In  simple  h\-per- 
trophy  this  picture  may  be  closel\'  imitated,  particularly  by  oblique 
sections  or  when  desquamated  cells  fill  the  lumen  of  the  gland.  These 
cells  stain  poorly  in  contrast  to  the  deep  staining  of  the  carcinoma 
cells,  and  besides,  the  cells  of  the  hypertrophied  glands  retain  the  normal 
form,  while  in  the  malignant  cells  there  is  a  deviation  from  the  normal 
toward  a  cuboidal  or  spheroidal  form.  Usualh"  in  some  region  of  the 
specimen  a  definite  invasion  of  the  periglandular  tissue  can  be  made 
out.      1  hese  pictures  resemble  closely  those  of  senile  parench\matous 

'  Deutsch.  Ztschr.  f.  Chir.,  1899,  liii,  126. 


526  TUMORS  OF  THE  URINARY  ORGANS 

hypertrophy  of  the  female  breast,  and  the  same  precautions  are  neces- 
sary in  arrivmg  at  a  conclusion. 

In  the  simple  type  solid  cancer  nests  are  present.  In  rare  instances 
the  connective  tissue  predominates,  often  to  such  a  degree  as  to  warrant 
the  term  scirrhus,  which  is  often  applied  to  them.  The  cells  are  small 
and  spheroidal,  often  Httle  larger  than  the  round  cells  of  inflamma- 
tion. Thev  often  infiltrate  the  connective  tissue  diffusely,  and  may 
simulate  infiltrative  processes  or  small  round-celled  sarcomas.  Regions 
can  usually  be  found  in  which  the  alveolar  arrangement  is  sufl&ciently 
characteristic  to  permit  a  positive  opinion.  Both  types  are  often  present, 
glandular  in  some  regions,  and  typically  alveolar  in  others.  Careful 
examination  of  all  parts  of  the  tumor  will  seldom  fail  to  remove  doubt 
as  to  Its  nature. 

Symptoms  and  Clinical  Course. — In  many  instances  of  carcinoma  of 
the  prostate  the  patient  gives  a  history  of  many  years  of  urinary  dis- 
turbance identical  with  that  usually  attending  hypertrophied  prostates, 
and  it  is  probable  that  in  such  cases  the  malignant  process  is  engrafted 
upon  such  a  condition.  In  early  carcinomas,  at  any  rate,  the  svmptoms 
are  those  of  urinary  retention  and  the  resulting  bladder  irritation. 
The   chief  svmptoms   may   be   taken   up   in   order. 

Retention. — Disturbance  of  micturition  may  be  identical  with  that 
caused  by  glandular  enlargement,  and  exacerbations  and  remissions  are 
less  likely  to  occur  than  in  the  benign  malady  and  the  residual  urine 
is  less  than  in  benign  obstruction  of  equal  degree,  perhaps  because  of 
its  persistenc}'  and  rapid  development. 

Hematuria. — Blood  in  the  urine  is  often  regarded  as  an  earh'  symp- 
tom, but  when  its  pathogenesis  is  remembered  it  is  clear  that  this  can- 
not be  so.  As  clinical  evidence  it  is  of  little  value  except  to  indicate 
that  the  disease  has  progressed  beyond  the  hope  of  cure.  This  is  true 
when  the  blood  comes  from  extension  of  the  growth  into  the  bladder, 
less  certainly  so  when  the  source  of  hemorrhage  is  the  prostatic  urethra. 
A  disposition  to  bleed  more  freely  upon  instrumentation  is  of  greater 
value  than  spontaneous  hemorrhage  if  the  operator  is  sufficientl}'  skilled 
to  estimate  the  amount  of  traumatism  he  is  inflicting. 

Pain. — Discomfort  in  the  region  of  the  prostate  may  be  an  early 
Sj^mptom,  and  is  explained  on  the  supposition  of  glandular  retention. 
Pain  which  is  felt  only  between  acts  of  micturition  is  very  suggestive. 
The  characteristic  pains  are  sharp  and  lancinating  and  are  referred 
to  the  glans  penis,  perineum,  hips,  and  thighs,  and  usuallv  indicate 
an  advanced  stage  of  the  disease.  As  the  disease  progresses  each  of 
these  symptoms  becomes  aggravated.  Usually  the  retention  causes 
damage  to  the  bladder  and  kidneys  which  is  fatal.  Occasionally  the 
rectum  is  invaded,  and  the  vessels  of  the  pelvis  may  be  compressed. 


77  Mnks  or    11 II:    I'ROSr.lTE 


iVli 


Diagnosis.  I  In  (.jusi-  of  ;i  iiiiii.ii\  ohsti  uction  slioiild  ;ilw;i\s  W- 
S()U«ilu,  i;in.iii()m;i  In  in«;  ;il\\;i\s  ic-^aick-d  as  a  possihilitw  foi  ir  is  upon 
physical  tA.imm.itKin  .iloiic  iliai  ilu  diagnosis  clt|>(iuls.  Tin-  feci  iiii- 
parrt'd  to  tin  souiul  is  nUcu  tlist  iiu  ii\  i-.  |()ll\  '  liktiu-d  ir  to  rlu-  feci  of 
^toiir.  It  is  iiliiitual  with  tin  siiisation  unpaired  rliioiijili  rlu-  sound 
m  tin-  examination  ot  a  caiianoina  tons  niciiis.  Ihc  ic-sisranii-  is  \)\\- 
scnrcil  to  rlu-  ad\aiu-t-  ot"  rlu-  souiui  rhi()ii<i,lioin  tin-  cnriic-  Kn^rh  ot"  the 
prostaric  inc-rhia.  (  )n  K-cral  palparion  rlu-  \i\:\n(\  m  pair  or  all  of  its 
surface  pnseius  noiliilarions.  Ilusi-  ina\  hi-  a  tc\s  well-defined  bossela- 
rions  or  may   he  so  numerous  as  ro  render  rlu-  inrin-  surface  j^ranular. 

In  eirlur  cast-  ir  is  rlu-  hardness  rhar  is  characrerisric.  The  feel  im- 
parted ro  rlu-  tin^el  is  idenrical  wirh  rhar  of  carcinoma  of  rhe  cervix. 
K\en  when  rhe  nodule  is  deei^)!)  searetl,  rlu-  dinsir\-  ma\  he  apjueciared 
throuiih  the  layer  ot  normal  prostatic  tissue  just  as  a  carcinoma  of  the 
cer\ical  canal  can  he  detected  throug;h  the  vaginal  vault.  The  thicken- 
ing ot  rhe  mangle  herween  rhe  seminal  vesicles  ma\  he  detected  befofe 
the  nodulations  wirhin  the  prostate  can  be  detected.  .Another  sign, 
Hrst  noted  by  ^'oung,  which  appears  rather  earlier  is  the  thickening 
between  the  lobes  when  rectal  palpation  is  practised  with  the  c\sto- 
scope  /;/  situ.  In  the  non-caicinomatous  gland  the  beak  of  the  instru- 
ment can  be  felt,  but  when  malignancy  is  present  it  is  not  definitel\- 
palpable.  The  cystoscope  is  of  importance  in  determining  the  question 
of  bladder  invasion,  less  often  in  the  discovery  of  the  disease  when 
contined  to  the  prostate.  Granular  nodulations  of  the  prostatic  urethra 
ma)-  be  found  when  this  tract  is  invaded  earh'. 

Differential  Diagnosis. — The  great  densit\-  of  carcinoma  as  perceived 
on  rectal  palpation  is  distinctive  from  the  smooth  elastic  feel  of  h\per- 
troph\-.  A  i-esistance  to  the  tip  of  the  advancing  sound  throughout 
the  length  of  the  prostatic  urethra  speaks  for  carcinoma,  while  in  simple 
enlargement  the  obstruction  is  encountered  only  at  its  termination, 
and  ends  suddenh'  as  the  middle  lobe  is  passed.  When  invasion  of 
the  periprostatic  tissue  has  taken  place  the  nature  of  the  disease  is 
at  once  obvious,  and  the  only  question  which  can  arise  is  that  of  the 
origin  of  the  tumor.  Sarcomas  occur  in  \oung  persons,  grow  more 
rapidl\-,  are  smooth  and  elastic.  Tuberculosis  may  cause  a  sclerosis 
of  the  prostate  and  subsequent  nodulations,  but  the  rate  of  develop- 
ment and  the  presence  of  the  disease  in  the  bladder  or  testis  prevents 
confusion.  Cwsts  of  the  prostate  may  resemble  a  carcinoma  nodule, 
but  they  are  softer,  more  nearly  spherical,  and,  according  to  Guepin, 
their  contents  can  be  expressed  by  manipulation. 

'  .Arcli.  gen.  de  nu'd.,  1869,  xiii,  580. 


528  TUMORS  OF  THE  URINARY  ORGANS 

Prognosis. — Carcinoma  of  the  prostate  when  untreated  may  run  a 
slow  course,  and  the  duration  of  the  disease  must  usually  be  calculated 
in  terms  of  the  urinary  disturbance  or  the  presence  of  metastases. 

Treatment. — In  the  presence  of  retention  from  advanced  malignancy 
suprapubic  drainage  offers  temporary  relief.  When  recognized  early, 
radical  removal  offers  some  hope  of  a  cure.  The  prostatic  capsule,  the 
seminal  vesicles  so  far  as  possible,  and  a  part  of  the  trigone  in  front  of 
the  urethral  opening  must  be  removed.  The  attachment  of  the  urethra 
to  the  opening  left  in  the  bladder  completes  the  operation  as  practised 
by  Young. 

Sarcoma. — Not  more  than  twenty  authentic  cases  are  to  be  found 
in  the  literature. ^  They  affect  the  young  chiefly,  but  are  seen  at  any 
age.  They  form  globular  tumors  of  soft  consistency,  usually  of  rapid 
growth.  All  cell  types  are  represented.  In  some  instances  the  tumors 
have  extended  out  of  the  pelvis  into  the  abdomen  or  ulcerated  through 
the  perineum,  and  they  are  usually  as  large  as  a  fist  or  larger  when  first 
discovered.      Attempts   at   removal   have   succeeded   only  in   one  case.- 

Rare  Tumors  of  the  Prostate.-' — Retention  cysts,  fibromas,  myomas, 
and  adenomas  are  sometimes  incidentally  observed,  usually  associated 
with  senile  hypertrophy.  Of  these,  the  cysts  alone  are  of  clinical  impor- 
tance. They  usually  occur  from  occlusion  of  outlet  ducts,  but  may 
result  from  chronic  abscesses  or  from  hydatids.  Mixed  tumors  have 
been  observed.^ 


TUMORS    OF   THE   BLADDER 

In  no  other  region  of  the  body  is  the  fact  that  tumors  are  not  a 
state  but  a  process  so  plainly  demonstrated  as  in  the  urinary  bladder 
because  of  the  uncertain  division  between  the  benign  and  malignant. 
Though  a  number  of  connective-tissue  tumors  are  found  in  this  region, 
they  are  rare  in  comparison  with  the  epithelial  tumors.  It  is  the  latter 
group  that  defies  a  division  into  benign  and  malignant.  The  common 
villiform  tumor  of  the  bladder,  called  by  Rokitansky  villiform  carci- 
noma (Zottenkrebs),  which  is  no  doubt  often  benign,  carries  within  it 
subtle  potentialities  of  malignancy,  so  that  practitioners  accustomed 
to  deal  with  this  variety  of  tumor  are  always  apprehensive,  no  matter 
how  emphatically  in  favor  of  benignancy  the  microscope  report  may  be. 

'  Graetzer,  Inaug.  Diss.,  Wurzburg,  1895. 
-  Socin,  Handb.  d.  Chir.,  Pitha,  Billroth,  iii,  p.  no. 

^  For    literature    see    Socin  and    Burkhardt,  Die    Verletzung    und    Krankheiten    der 
Prostata,  Enke,  Stuttgart,  1902. 

*  See  Kaufmann  in  Socin  and  Burkhardt,  loc.  cit.,  p.  395. 


77   I/O  A' ,S'  Ol    Till:    lil.lhDrM  :)2«> 

I'oi  ;i  lime  ilic  opinion  ot  l\okit;iiisk\'  ;i.s  to  iIk  iii;ili;in;iiu\  of  rlicse 
jiiowths  \\;is  iliscucliticl,  l)iit  ;is  opn ati\f  experience  lias  become  j^ieater 
there  is  ;i  t;eiuial  disposition  to  icxcir  to  the  original  opinion,  alrhoii^li 
sonu'  ant  hoi  itat  i\  c-  xoicis  ihsscnt  from  this  \\v\\.  I  he  most  notal)le 
ol  tlu'se  are  Nir/t-'  and  Casper.''  I  he  Ioiiik  r  has  had  e.\|)ei  unce  of 
177  cases  ol  heni^n  tumors,  and  the  latter  estimates  that  in  iiS  cases 
72  per  cent,  wvw  luni^n.  It  is  of  interest  to  noti-  that  hoth  of  these 
ileal  with  \  I  r\  small  tumors  ca|iahlc  ol  removal  h\  cndosi-oincal  means. 
I  hese  diverj^ent  views  mav  he  harmoni/i-d  l)\  the  assumption  that 
tluse  past  masters  of  the  ait  of  \csical  exploration  recf)^nize  tiim<jrs 
at  an  earlier  sta<2;e  than  lalls  to  the  lot  of  the  averaji;e  siu<i;eon  and  does 
nor  \itiatt-  the  common  helief  that  when  the  rumors  present  them- 
selves to  the  majority  of  surgeons  the\'  have  passed  the  stage  when 
they  can  be  removed  by  endovesical  operations  and  have  become  malig- 
nant. It  would  seem,  therefore,  that  the  villiform  tumors  of  the  bladder 
should  aKva\'s  be  regarded  with  apprehension,  and  an  arrem|-)t  at  a 
distinct  division  into  benign  and  malignant  varieties  should  for  the 
present  be  held  in  abeyance  and  all  \illiform  tumors  classed  together. 

Villiform  Tumors  of  the  Bladder.  Etiology. —  In  no  other  region 
does  the  relation  between  chronic  irritation  and  tumor  formation  appear 
more  plainly.  This  is  especiall}'  marked  in  connection  with  cases  of 
bilharzia  and  with  workers  in  aniline  dyes,  in  which  this  relation  stands 
out  with  the  clearness  of  a  laborator\'  experiment.  Goebel,^  who  has 
studied  48  tumors  due  to  bilharzia  irritation,  found  24  of  them  malig- 
nant. One  was  a  benign  papilloma,  and  the  remainder  were  granulo- 
matous with  accompanying  proliferation  of  the  epithelium.  Milton 
doubts  the  genuineness  of  these  carcinomas.  The  frequent  occur- 
rence of  bladder  papillomas  in  aniline  workers,  first  pointed  out  by 
Rehn,^  presents  an  additional  interest  in  that  the  nature  of  the  irritant 
can  be  expressed  in  terms  of  chemistr\',  and  it  is  of  interest  to  note  that 
the  dye  most  at  fault  is  fuchsin.  In  23  cases  reported  by  Rehn,-^  18 
were  carcinomatous. 

The  interesting  fact  from  a  theoretical  point  ma\'  be  noted  that  a 
like  irritant  ma\-  give  rise  to  both  benign  and  malignant  rumors.  Evi- 
dence is  not  at  hand  to  warrant  an  opinion  as  to  whether  or  not  these 
types  represent  stages  in  the  same  process  or  fundamentally  different 
processes,  but  evidence  points  to  the  former  possibility.     Tumors  arising 


^  Lehrbucli  der  Kystoskopie,  II  Aufl.,  Bergmann,  Wicshaclfii,  1907. 
-  Berlin,  klin.  Woch.,  1908,  xlv,  303. 
•■'  Ztschr.  f.  Krebsforsch.,  1905,  iii,  369. 
■•  \'erhandl.  d.  deutsch.  Gesellsch.  f.  Chir..  1895,  xxiv,  240. 
°  Ibid.,  1904,  xxxiii,  231. 
34 


530 


TUMORS  OF  THE  URINARY  ORGANS 


from  unknown  causes  have  been  demonstrated  to  have  a  sequential 
relationship;  that  is,  tumors  presenting  no  microscopic  evidence  of 
maHgnancy  at  the  first  operation  do  present  such  evidence  in  their 
recurrence.  This  relationship  is  further  disclosed  by  the  occurrence 
of  metastases  in  the  abdominal  wound  after  the  removal  of  apparently 
benign  tumors.  In  this  regard  they  show  a  striking  resemblance  to 
the    papillary   cystomas    of    the    ovary.      Papillomas    of   the    bladder. 

Fig.  382 


Multiple  benign  papilloma  of  the  bladder.     (Watson  and  Cunningham.) 


secondary  to  like  tumors  of  the  pelvis  of  the  kidney,  have  been 
reported.  That  the  common  seat  of  bladder  tumors  is  on  the  base 
of  the  bladder  at  or  near  the  urethral  opening  is  suggestive  of  the 
influence  of  irritation. 

Macroscopic  Appearance. — When  viewed  with  the  cystoscope  or  in 
the  opened  bladder  filled  with  fluid  the  villi  of  which  these  tumors  are 
composed  float,  and  when  the  fluid  is  agitated  they  wave  like  the  leaves 


rr.MfjRs  or  riii:  hliddik 


o:ii 


ot  a  Itrn  in  tlic  wiiul.  Tlu  iiulix  kIikiI  st;ilks  ;iic  ;itt;uiitcl  at  a  coniiiKjn 
base,  or  sf\i  ral  ma\  iiniti-  htfnic  \\u\  re  aili  tin-  pidiik-  '  Kig.  382).  The 
base-  varus  in  rhickiuss;  ofrtii  ir  is  small  ami  rlmad-likc,  and  not  infre- 
(lut-ntl)  it  Ihcoiihs  twisttcl  oH  :iiul  spontaiuoiis  curi-  iisiilts.  In  some 
cases,  paitKulail\  in  riiosi-  wirli  a  tcntit-nc)  to  nialiti;nanc\  ,  or  thf)se 
alreacl\-  malignant,  riu-  hast-  is  bioadtr  (  Fijr.  ;vS^).  It  is  this  point  that 
is  most  valuahk-  in  anivinf^  at  a  clinical  jiid^nunt.  In  the  malij^nant 
t\  pe  the  hladder  wall  is  more  or  less  thickened,  though  there  may  be 
cellular  nnasion  that  is  not  macroscopicall\'  discernible;  the  villi  may 
be  much  thickened  b\-  infiltration,  so  that  a  dense  mass  is  formed,  from 
the  surface  of"  which  short  villi  project.  In  this  sta^e  malif:nanc\- 
cannot  be  doubted. 

Kic.  383 


Carcinoma  of  the   bladder,  resembling  beni-n  papilloma.     (Waison  and  Cunnincham  ) 


When  the  base  becomes  invaded  extensive  involvement  of  the  bladder 
wall  may  follow,  or  the  intravesicular  portion  of  the  tumor  ma}-  grow, 
the  more  rapidly  filling  the  bladder  with  a  cauliflower  mass.  The  tumor 
may  attack  the  pelvic  organs,  and  distant  metastases,  particularh-  in 
the  liver,  may  follow. 

Microscopic  Appearance.-  In  the  benign  stage  there  is  a  central  con- 
nective-tissue stalk  bearing  the  bloodvessels.  Upon  this  the  cells  are 
arranged  columnar  fashion  about  the  base,  while  near  the  e.\tremit\- 
the\-  lie  more  obliquely.      The  cells  below  are  columnar,  but  toward  the 


532  TUMORS  OF  THE  URINARY  ORGANS 

extremity  they  are  oval,  with  prominent  oval  nuclei,  and  at  the  extremit}^ 
they  are  irregular  (Fig.  385).  ZuckerkandP  believes  it  is  possible  to 
detect  the  malignant  tendency  in  the  benign  by  the  presence  of  large 
cells  with  deeply  staining  nuclei.  The  malignant  type  shows  an  inva- 
sion into  the  connective  tissue  about  the  base.  This  usually  occurs 
as  columns  of  cells  which  may  retain  the  ovoid  shape  of  the  villi.  In 
order  to  determine  the  question  of  invasion  the  base  of  the  tumor  must 
be  examined.  Often  this  has  not  been  removed,  and  when  it  has  been 
removed  it  may  no  longer  be  recognizable  when  the  tissue  reaches  the 
laboratory.  It  is  this  difficulty  in  securing  suitable  sections  that 
makes  a  distinction  between  the  benign  and  malignant  so  difficult  and 
uncertain. 

Clinical  Course. — Fenwick-  divides  the  clinical  course  into  the  latent, 
the  hemorrhagic,  and  cystic  stages.  In  the  first  the  patient  is  unaware 
of  any  disease,  save,  perhaps,  an  ill-defined  discomfort.  Usually,  the 
first  sign  of  disease  is  a  painless  hematuria.  The  blood  appears  during 
the  flow  of  urine  and  is  more  likely  to  be  most  severe  at  the  end 
of  micturition,  particularly  if  the  tumor  is  large  enough  to  be  com- 
pressed b}'  the  contracting  bladder.  These  hemorrhages  appear  at 
intervals,  are  inclined  to  disappear  on  rest,  only  to  reappear  sponta- 
neously or  after  violent  exercise.  Indefinite  pain  in  the  bladder  may 
be  experienced  when  the  urine  is  still  normal.  When  infection  takes 
place  spontaneously  or  after  instrumentation,  the  symptoms  of  a  cystitis 
is  implanted  upon  that  of  hematuria.  Pain  in  the  region  of  the  bladder, 
perineum,  hip,  thigh,  or  even  in  the  region  of  the  kidney  may  take  place. 
With  the  pain  may  appear  evidences  of  septic  absorption  and  second- 
ary infection  of  the  kidney.  Rarely,  the  ureters  become  occluded,  so 
that  a  hydronephrosis  or  a  pyonephrosis  results.  In  the  malignant 
type  invasion  of  the  perivesicular  tissue  may  give  rise  to  associated 
symptoms. 

Diagnosis. — The  nature  of  a  bladder  affection  must  be  determined 
first  to  be  a  tumor,  after  which  the  nature  of  the  tumor  ma}^  be  estab- 
lished. The  presence  of  a  painless  spontaneous  hematuria  always  sug- 
gests the  possibility  of  tumor.  Usually  the  simplest  manner  of  deciding 
this  point  is  by  means  of  the  cystoscope.  This  may  be  attended  with 
difficulties  if  the  tumor  is  large  enough  to  fill  a  considerable  portion 
of  the  bladder,  or  if  hemorrhage  is  profuse.  If  the  hemorrhage  occurs 
with  such  rapidity  that  irrigation  does  not  permit  of  a  view,  this  is  in 
itself  strong  evidence  that  a  tumor  is  present.  Large  tumors  which 
interfere  with  the  view  of  the  cystoscope  may  be  felt  upon  bimanual 

1  Verhandl.  d.  deutsch.  Gesellsch.  f.  Urol.,  1909. 

-  Tumors  of  the  Urinary  Bladder,  Churchill,  London,  1901. 


riMORS  Ol     rill:    lil.lhhl.K 
V\i..  3S4 


i33 


Carcinoma  of  the  bladder. 


Fig.  385 


FtAu<cc  73«»-n«ift-4-0/ 


>x 


v^. 


x^* 


\  illi  of  benign  papilloma,  showing  epithelial  covering  central  stem  and  the  connec- 
tion of  the  villi  with  the  base  of  the  tumor.  Longitudinal  section.  (Watson  and 
Cunningham.) 


534  TUMORS  OF  THE  URINARY  ORGANS 

palpation.  When  a  tumor  is  found  to  be  small,  single,  and  with  a  con- 
stricted base,  there  is  hope  that  it  is  benign.  If  the  base  is  broad,  the 
villi  thick,  incapable  of  movement,  and  particularl}^  if  the  base  is 
infiltrated,  the  tumor  is  likely  malignant.  The  density  may  be  deter- 
mined in  some  instances  by  careful  manipulation  with  the  cystoscope. 
Usualh-  the  onlv  result  of  this  manipulation  is  to  excite  a  hemorrhage 
that  may  be  embarrassing. 

Nodular  Epithelial  Tumors. — Villous  tumors  by  extensive  infil- 
tration may  form  nodular  masses.  The  nature  of  these  is  usually  mani- 
fest by  the  remains  of  vilH  covering  the  surface.  In  some  instances 
nodular  masses  form  independent  of  viUi  (Fig.  384).  These  Fenwick^ 
calls  bald  carcinomas.  They  are  usually  easily  recognized  and  run 
the  same  course  as  the  villous  type. 

Prognosis. — Epithelial  tumors  of  the  bladder,  because  of  their  uncer- 
tain nature,  always  give  a  dubious  prognosis.  Many  of  the  small  benign 
ones  give  a  good  prognosis.  On  the  other  hand,  small  tumors,  appar- 
ently benign,  recur  and  present  undoubted  evidence  of  malignancy. 
After  the  base  of  the  bladder  has  become  infiltrated  the  prognosis  is 
absolutely  bad. 

Treatment. — Skilled  operators  remove  many  of  the  small  tumors 
through  the  operating  cystoscope.  The  larger  ones,  because  of  the 
uncertainty  of  complete  removal,  had  best  be  attacked  by  suprapubic 
section.  The  usual  seat  is  at  the  trigone,  and  the  most  convenient 
method  is  excision  by  the  cautery.  When  the  tumor  occupies  the  free 
portion  a  transperitoneal  operation  with  immediate  closure  may  be 
practised.  When  a  ureteral  orifice  is  occluded,  a  section  of  this  with 
reimplantation  may  be  demanded.  When  the  bladder  is  extensively 
involved,  the  tumor  is  inoperable.  The  removal  of  the  entire  bladder 
has  not  been  satisfactory  except  from  a  technical  standpoint.  When 
the  urethral  orifice  is  occluded  a  suprapubic  drainage  may  give  tempo- 
rary relief.  A  suprapubic  section  may  be  required  to  control  hemor- 
rhage in  cases  otherwise  inoperable.  When  the  entire  thickness  of  the 
bladder  wall  is  mvolved  any  treatment  is  useless.  Results  are  good  when 
the  pedicle  is  well  formed  and  there  is  no  infiltration  about  the  base. 

Results  of  Operation. — Cathelin^  reports  32  cases  of  carcinoma  of  the 
bladder,  all  of  which  ended  fatally.  Von  Fisch,  in  300  cases,  103  of 
which  were  benign,  reports  recurrence  in  40  per  cent.;  in  98  suspicious 
cases  there  were  60  per  cent,  recurrences;  while  in  95  certainly  cancerous, 
all  recurred.  According  to  Watson  and  Cunningham,'*  in  141  papillomas 
75  per  cent,  remained  free.     In  125  carcinomas  65  per  cent,  recurred. 

1  Loc.  cit.  '  Medecine  prat.,  1907,  iii,  133. 

3  Diseases  of  the  Genito-urinary  Organs,  Lea  &  Febiger,  Philadelphia,  1907. 


TUMORS  or  rill  HI.  I  DPI.  k  r).3.j 

Rare  Tumors.  Sarcomas.  Munwcs'  colkctrd  107  cases.  These 
tumors  an-  most  trt(|iuiu  in  tlu-  early  \ears  of  life.  I'liey  are  usually 
solitary  ami  an-  atracluil  l\\  a  broad  base,  or  inHltrate  the  bladder 
\\all.   or   iii\  aiK-    rhc   entire   pelvis.       1  hey    usuall\    run   a    rapid   course. 

Myomas.  I  hesi  are  even  more  rare  than  the  sarccmias.  About 
;o  cases  ha\  e  been  leported.'-  1  hey  resemble  urerme  m\ omas  in  struc- 
ture and  habit  ot  j;ro\Nth.  1  hey  actually  become  so  lar^e  as  to  be  con- 
tused with  uterine  myomas.  Ihey  ma\  bear  any  relation  to  the  vesical 
walls  but  are  usuall\'  between  the  muscle  and  mucous  layer. ^  Rhabdo- 
m\()mas  are  rarer  than  the  unstriated  varietw  The  unstriated  muscle 
cells  are  interminjiled  with  embryonal  cells. 

Adenomas.'  I  hese  probabl)'  result  from  displaced  prostatic  tissue, 
because  corpora  amylacea  have  been  obser\ed  in  them. 

Cysts.  Brongersma'  was  able  to  collect  but  4  cases.  They  probably 
result  trom  dilated  lymph  spaces. 

Hemangiomas. — Telangiectases  have  been  reported  in  the  bladder. 
1  hey  usually  appear  as  an  extension  of  similar  dilatations  of  other 
peKic   \eins.'' 

Syncytiomas. — Tumors  with  large  polyhedral  cells  have  been  reported 
as  syncytial  in  origin.  These  cells  are  sometimes  seen  in  the  summits 
of  papillomas,  and  \  enulet^  regards  them  as  transformations  of  epi- 
dermoidal  bladder  carcinomas. 

'  Ztschr.  f.  Urol.,  1910,  iv,  880. 
-  Blum,  Folia  Urologica,  1910,  v,  i. 

•^  Monckeberg,  Virchow's  Arch.  f.  path.  Anat.,  1907,  clxxxvii,  471. 
■•  Scudder,  Boston  Med.  and  Surg.  Jour.,  1908,  clviii,  523;  Ba\er,  \'ircho\v's  Arch.  f. 
path.  Anat.,  1909,  cxcvi,  350. 
^Ztschr.  f.  Urol.,  1908,  ii,  489. 
''  Bachrach,  Folia  Urologica,  1909,  iv,  loi. 
^  Virchow's  Arch.  f.  path.  Anat.,  1909,  cxcvi,  73. 


CHAPTER    XXXVI  I 

MYOMA   OF   THE   UTERUS    fFIBROMAS    OF   THE   UTERUS, 
FIBROIDS,   FIBROMYOMAS   OF  THE  UTERUS),  ADENO- 
MYOMA  OF  THE  UTERUS,  MYOMA  OF  THE  ROUND 
LIGAMENT,  TUMORS  OF  THE   ROUND   LIGA- 
MENT,  PREGNANCY   IN   MYOMA 

MYOMA    OF   THE   UTERUS 

General  Conception. — Myomas  of  the  uterus  are  composed  of  muscle 
and  fibrous  tissues.  Pure  fibromas  and  pure  myomas  are  sometimes 
observed,  but  the  majority  of  them  are  made  up  of  fibrous  and  muscular 
tissue  in  varying  proportions.  It  would  appear  from  their  structure 
that  the  compound  term  fibromyoma  would  be  the  most  nearly  correct. 
The  tissue  which  characterizes  them  clinically  is,  however,  the  muscle 
tissue,  and  for  practical  purposes  at  least  the  fibrous  element  may 
be  disregarded  in  the  designation. 

Classification. — Any  portion  of  the  uterine  or  cervical  musculature 
may  be  the  seat  of  myoma.  It  is  usual,  because  of  the  diff^erent  cHnical 
manifestations,  to  consider  separately  those  of  the  body  and  those  of 
the  cervix.  Those  of  the  body  begin,  for  the  most  part,  within  the 
uterine  musculature.  These  are  circumscribed  tumors,  and  in  their 
development  push  aside  the  uterine  wall  in  all  directions  equally,  remain- 
ing throughout  surrounded  b}^  uterine  wall  (interstitial),  or  they  may 
develop  more  toward  one  or  the  other  of  the  surfaces  of  the  muscle. 
The  contractions  of  the  muscle  fibers  seem  to  favor  the  expulsion  of 
the  tumor  from  within  the  uterine  wall.  When  this  succeeds  toward 
the  mucous  surface,  the  uterine  musculature  no  longer  surrounds  the 
tumor  on  the  side  nearest  the  uterine  cavity  (submucous),  and  when 
the  extension  is  toward  the  abdominal  cavity,  the  tumor  has  only  a 
covering  of  peritoneum  (subserous).  Uterine  myomas  are  classified, 
therefore,  according  to  their  topographical  relations  to  the  uterine 
wall. 

Tumors  in  these  different  locations  give  different  cHnical  symptoms, 
and  it  will  be  worth  while  to  stud}'  the  life  histor}^  of  these  classes  more 
minutely. 

Interstitial  (Intramural)  Myomas  (Fig.  386). — It  is  probable  that  all 
uterine  myomas  begin   as  interstitial  tumors,  and   that  in   their  subse- 


/  \  Ti.Rsriri.ii.  \i)(/\i,/s 


:)37 


(|Liciit   (.li\  clopnu  lit    ilu-\    fiiul    to    l)c    toicitl    mull-  or   less   ro   the  (juttr 
or  inner  surface  of   the  orjian.      In  tin    interstitial  variety  the  tumor  is 


Fic.  3S6 

^^1 

^I^^Cl%^^h  ^t^JBi^  ^^^I^^ 

'¥'-^H 

^3^H 

^'^^^^fi^l 

Hl^Vvf 

Interstitial  ni\'onia. 
Fig.  387 


Submucous  nnumas. 


surrounded  on  all  sides  by  muscle  hbers  which  have  undergone  hyper- 
troph\-.      Immediately  about  the  tumor  proper,  there  is  usually  a  la\er 


538 


MYOMA  OF  THE  UTERUS 


of  loose  fibrous  tissue  which  contains  the  bloodvessels.  The  uterine 
wall  proliferates  with  the  growing  tumor,  and  tumors  of  considerable 
size  may  thus  be  surrounded  by  a  capsule  of  uterine  tissue,  not  a  small 
part  of  the  tumor  being  supplied  by  the  proliferated  uterine  wall. 

Submucous  Myomas  (Fig.  387). — These  tumors  spring  from  the  myome- 
trium, and  the  submucous  connective  tissue.  The  continued  contrac- 
tions of  the  uterine  muscle  may  succeed  in  forcing  the  tumor  more  and 
more  into  the  cavity  of  the  uterus  until  it  becomes  entirely  outside 
the  muscle.    Thrombosis  of  the  nutrient  vessels  may  cause  the  tumor 

Fig.  388 


Subserous  myoma;  narrow  pedicle  attached  to  the  fundus  of  an  unaltered  uterus. 


to  detach  itself  from  the  uterus  and  result  in  a  spontaneous  cure,  but 
extensive  gangrenous  changes  are  more  likely  to  occur.  When  the 
tumor  encroaches  upon  the  mucosa  it  causes  an  increased  vascularity 
which  leads  to  one  of  the  most  common  symptoms  of  fibroids,  hemor- 
rhage. 

Subserous  (Fig.  388). — In  this  variety  the  tumor  projects  toward  the 
abdominal  cavity.  It  rests  upon  the  uterine  musculature  and  is  covered 
by  the  peritoneum.  Sometimes  tumors  lie  embedded  in  the  uterine 
musculature,  but  project  with  a  part  of  their  surface  beyond  the  uterine 
wall.    They  may,  on  the  other  hand,  be  attached  to  the  uterus  by  a  small 


/  \  IK  II.K,  l\ll:\  /fJt  S   M)  OM.I 


539 


picluli-  iiKuU-  ii|)  (.1  pciiiDiit  iiiii,  ;i  si)i;ill  jinotitii  of  hl)r()us  tissue  and 
MoDiKi'sscls.  I  Ills  pccluii  iii;i\  he  so  siikiII  tli;it  tuisfin^  rradilv  occurs 
and  siihsr(|mii(  necrosis  of  i  lie  iiinioi  iiia\  ksiiIi.  IJriuccn  ilu-sc  luo 
(.xticnus,  r\(i\    liiadarion  nia\    In-  tiuountircd. 

Myoma  of  the  Cervix.  It  is  cusr()inar\  to  class  ilu  tninors  ot'  the 
ceixica!  portion  of  ilit  uiiiiis  as  a  scpaiatc  ^loiij).  This  is  a  I'linical 
coimnuiui'  since  tlu\  lia\c  a  |)aitunlar  obstetrical  si{i;niHcaiu-c.  'I'liev 
arc  \(,i\  niiich  lanr  than  those  oi"  tin-  corpus;  in  fact,  v.  Winckel  declares 
that  lu-  has  iu\ii  sicn  a  case.  The  chief  (lil+iciih\  conies  in  detertiiin- 
inu   what   shall    lu-    niiardi-d    as   a   cerxical    iinoma.       Those   which   arise 


Fig.  389 


5Bsrfs  (Oio 


Interstitial  and  submucous  nnumas  of  the  uterus. 


within  the  body  and  encroach  upon  the  cervix  are  not  so  rare,  making 
about  5  to  8  per  cent,  of  uterine  myomas.  If,  however,  b\-  the  term 
cervical  myoma  only  those  arising  within  the  cervix  are  meant,  they 
are  very  rare  tumors,  though  examples  are  recorded  in  the  literature. 
Their  rarity  can  occasion  no  surprise  since  the  amount  of  muscular 
tissue  within  the  cervix  grows  progressively  less  as  the  external  os  is 
approached.     The)-  are  usually  almost  entireh'  fibrous. 

Intraligamentous  Myoma. —  If,  instead  of  projecting  into  the  free 
peritoneal  ca\iry,  a  tumor  advances  into  the  broad  ligament,  it  be- 
comes covered  by  the  peritoneum  of  that  structure  and  the  very  appro- 
priate name  of  intraligamentous  myoma  is  applied   to  it.     These  bear 


540  MYOMA  OF  THE  UTERUS 

the  same  relation  to  the  uterine  wall  and  cavity  as  the  subserous,  the 
difference  being  purely  one  of  location. 

This  classification  of  uterine  myomas  according  to  their  relation 
to  the  uterine  wall,  as  proposed  by  Gusserow,^  is  useful  because  the 
different  types  run  different  clinical  courses. 

The  types,  however,  are  not  always  clearly  defined,  and  surround- 
ing both  the  subserous  and  submucous  tumors  there  is  frequently  some 
fibrous  and  some  muscular  tissue.  This  is  hyperplastic  tissue,  and  it 
frequently  makes  up  a  large  part  of  the  tumor  itself  and  projects  with 
it  bej^ond  the  surface,  thus  typifying  all  three  classes  (Fig.  389).  The 
newly  formed  tissue  may  form  a  thick  capsule,  from  which  the  tumor 
is  readily  shelled  out,  but  it  may,  however,  on  account  of  its  volume, 
require  removal.  It  comes  about,  therefore,  that  in  man}'  cases  it  is 
unimportant  whether  or  not  a  given  tumor  shall  be  regarded  as  inter- 
stitial or  submucous.  The  symptomatology  and  clinical  course  of  these 
types  IS  often  very  different,  and  formerly  the  whole  plan  of  treat- 
ment depended  upon  which  was  present.  But  since  all  myomas  are 
coming  to  be  regarded  as  proper  objects  for  surgical  treatment,  the 
classification  has  lost  much  of  its  importance.  The  general  plan  of 
treatment  is  now  the  same  for  all,  and  the  type  makes  only  a  slight 
difference  m  detail. 

Influence  on  the  Form  of  the  Uterus. — The  form  of  the  uterus  may 
undergo  marked  changes,  depending  upon  the  size,  location,  and  number 
of  tumors.  Tumors  which  encroach  upon  the  cavity  of  the  uterus 
distort  the  canal,  and  when  they  are  large  the  cavity  accommodates 
Itself  to  the  growing  tumor.  If  the  tumor  grows  within  the  wall  (inter- 
stitial), the  entire  uterus  may  be  much  lengthened  so  greath'  that  the 
cavity  is  deepened  to  6  or  8  inches  or  more.  Subserous  tumors  cause 
the  least  deformity;  in  fact,  the  general  shape  of  the  uterus  may  be 
unchanged  if  the  pedicle  of  the  tumor  is  small.  When  these  various 
types  are  combined  they  may  cause  every  conceivable  deviation  from 
the  normal  size  and  form;  in  fact,  it  may  be  extremely  difficult  to  deter- 
mine in  some  cases  what  portion  of  the  mass  represents  the  normal 
uterine  bod}/. 

Accidents  Occurring  in  Course  of  Development. — Torsion  of  the  Pedicle. 
— In  subserous  myomas,  when  the  pedicle  becomes  elongated  and 
thin,  the  tumor  may  turn  upon  its  own  axis  (Fig.  390)  after  the  manner 
of  ovarian  tumors.  The  gravity  of  the  accident  depends  upon  the 
effect  of  the  torsion  on  the  nutrient  vessels  of  the  tumor.  If  these 
are  completely  cut  off,  necrosis  must  follow;  if  only  partly  interfered 
with,    inflammation    with    adhesions    to    the    surrounding    organs    ma}^ 

^  Handbuch  der  Frauenkrankheiten,  Bd.  ii,  Enke,  Stuttgart,  1886. 


/■:.\7ki  s/()\  /\    \i)(>\i  I  or  rill,  i  irkcs 


541 


iisuli     oi    sonn-   ol    ilif    ilcnciuiwtions,   n()t;il)|\     iii\  xoul    oi    (.oIIokI,    iii;i\- 

Sequestration.  Il  fiom  toisioii  ol"  ih,  pcdulc  (,|  li,,,,)  orlu-i  causes, 
surh  as  f In omhosis,  ilu  niiiiuiii  \tssils  ol  ilu  (uiiior  Ixromc  ofclucled, 
it  nKi\  ariiuiri-  a  luw  a  i  tachiiuni  to  an  adiaicnt  pan,  usiialh  the  omt-n- 
tiini.'  I  lusi'  luw  at  lathimnis  ma\  siippK  the  needed  ninniiKnt  and 
rlu'  tumor  ma\  becoiiu-  ciuin-lv  separated  lioni  the  utcius  ami  letam 
its  arrai'hnunt  to  its  new  host.  Moit-  tVeipient  l\  ,  liovvcvcr.  rhe  arracli- 
'ii^'i'    '"   '111-   litems    IS    letaimil,  and    with    this    (h)iihh-    souixh-   of  blood 

Fk;.  39c 


"*^H 

^r      ^B 

■k'pW  s 

■ 

jj,.^v  ai              ^^^1 

Partial  torsion  of  the  pedicle  of  a  uterine  ni\<>nia. 

-supply  the  tumor  continues  to  develop.  This  condition  is  ver\-  common 
in  myomas  of  large  size.  The  vessels  of  the  omentum  dilate  to  an 
enormous  si/e  and  form  a  frequent  complication  during  operation. 

Extrusion.  \\  hen  a  tumor  becomes  submucous  the  continual  con- 
traction ot  the  uterme  muscle  tends  to  force  it  into  the  cavit\-  and 
thence  into  the  cervical  canal.  The  vessels  ma\-  become  occluded 
.and    the    tumor    may    be   graduall\     separated    and    expelled    from     the 


'  Cullen,  Jour.   Anicr.    Mt-d.   .As.soc,   1907,  xlix,   1994,  and    Knorr,   Jour.  Anier.  Med. 
Assoc,  1905,  xlv,   10. 


542 


MYOMA  OF   THE   UTERUS 


vagina,  and  a  spontaneous  cure  result.      Usually,  before  this  happy  end 
is  reached  necrosis  or  infection  ensues  and  the  patient  dies. 

Inversion. —  In  the  attempt  to  extrude  the  tumor,  the  fundus  of  the 
uterus  may  be  drawn  down,  inverting  the  organ.  If  the  circulation 
becomes  cut  off,  the  uterus  as  well  as  the  tumor  may  become  necrotic. 

Fig.  391 


Colloid  degeneration  of  a  uterine  myoma  resulting  from  a  partly  twisted  pedicle. 


The  inverted  uterus  may  become  so  thmned  that  it  appears  as  a  pedicle 
of  the  tumor,  and  the  error  may  not  be  discovered  until  the  fundus  of 
the  uterus  and  perhaps  the  tubes  are  found  attached  to  the  severed 
tumor. 

Incarceration. — As   the   fibromatous  uterus   grows   it   may   fail   to   rise 
out  of  the  pelvis,  but  impinge  against  the  bony  wall  and  cause  pressure 


.1/ YXoMiroi -.s  /)/■:(:/■: \ /.k. mo \  :)4:i 

upon    tin    luiniil^oiinj;  ()ii;;ms.      lisriihi   (»f  tin-    nctiiin    oi    Mwdiln    m;i\' 
it'sulr,  ;uul   i;ml\    li\  ciKtiuphiosis  from  lonipifssion  ol  rlu-  unrtrs.' 

Secondary    Changes.     Atrophy.      I  luitr    diverse    inriuciuts,    myomas 
iiKiv    iiiuiii<;o  i()iisuKi;ilik-   irdiKtioii   in  sl/r.     At   rlu-  im-nopause  the\' 
shall'   rlu-   i;i-iu-ral   ati()pli\    ol"  rlu-  sc-.\iial   organs,   hur    lairh    disappear 
t'ntirtl\  ;  in  tatr,  tlu    o\arie.s  were  torinerly  removed  in  order  to  iruluee 
rhis  clianue.      I  he  decree  of  atrophy  following  the  meiu)pause  is  uncer- 
tain, aiul  tlu-  presence  of  the  tunu)r  ma\-  postpone  this  epoch.     I^rej^nancv 
.iiul   lahoi    nu)re  often   are   foilowi-d   h\    compii-re  disappearance  than   is 
rhe   nunopause,    hur  disappearance    in    an\'   evenr    must  be  considered 
a   urear   ranry.      W  hen   ir   does  occur   the  same  chanj^es   take  place  as 
occiu-  m   uteriiu-   nurscle  at   the  climacteric.       The   muscle  cells  become 
fatty    and    are  gradually    absorbed,  aiul  are    leplaced   h\    fibrous   tissue. 
Spontaneous    disappearance   is    much    less    t"re(]uent    than    indicated    b\- 
the  literature.     The  reason   for  this  is   that  hemorrha<i;e  was  the  chief 
symptom  which   rhe  advent  of  the  menopause  was  expected  to  relieve, 
and    it    undoubtedly   did    this   in    some   instances.      Unfortunately    the 
disappearance  of  hemorrhage  does  not  always  mean  a  cessation  of  the 
growth  of  the  tumor,  nor  does  it  preclude  other  complications  incident 
to  the  disease.     Many  of  the  degenerations,  notabl\-  of  the  hemorrhagic 
and  sarcomatous  t\pes,  are  especially  apt  to  appear  after  hemorrhage 
has  ceased.      It  is  particularh-  important  to  keep  these  facts  in  mind 
because  of  the  false  sense  of  security-  with  which  the  lait\-  regard  the 
cessation    of  hemorrhage.      Surgeons   generalh-    recognize    the    folh'    of 
awaiting  a  spontaneous  cure,  but  this  knowledge  has  not  \et  been  as 
full}-  disseminated  as  its  importance  warrants. 

Myxomatous  Degeneration.' — This  change  is  noted  with  considerable 
frequency  in  large  tumors.  It  involves,  first,  the  interstitial  fibrous 
tissue,  which  swells  up,  becomes  homogeneous,  and  then  liquefies.  The 
dense  bands  of  adult  fibrous  tissue  resist  the  degenerative  changes 
for  a  longer  time.  The\-  ma)-  be  seen  stretching  across  the  degenerated 
area  forming  a  network.  Finally,  these  too  liquefy  and  a  c\-st  is  formed 
(Pig.  392).  The  degeneration  of  the  fibrous  tissue  ma}-  cause  the  blood- 
vessels to  rupture  and  give  rise  to  hemorrhage  of  considerable  magnitude, 
which  may  increase  the  size  of  the  cyst  considerabh.  Immediatelv 
after  the  occurrence  of  the  hemorrhage,  fluid  or  coagulated  blood  ma\- 
be  expressed.  After  a  time,  however,  lytic  processes  take  place  and 
the  whole  becomes  straw-colored.  This  degeneration  is  due  to  lack  of 
nutrition,  and  is  most  likel\-  to  occur  in  rapidh"  growing  tumors  at  or 
after  the  menopause.  It  is  in  this  wa\-  that  most  of  the  c\stic  m\-omas 
arise. 

'  Kno.x,  Amer.  Jour.  Obst.,  1900,  xllv,  348. 

-  Piquand,  Revue  de  cliirurgie,  1906,  xxxiii,  652. 


544 


MYOMA  OF  THE  UTERUS 


Calcareous  Infiltration. — Calcareous  infiltration  maj^  occur  in  m3'omas, 
especial!)^    under    two    conditions — when    the}"    have    become    necrotic 

Fig.  392 


Myxoid  degeneration  of  the  uterus  with  cyst  formation. 
Fig.  393 


Calcareous  myoma. 


M-CROSIS   /A    MYo.M  /  OF   THE   UTERI'S  545 

tioiii  (.list  III  Ikiiuis  111  tlu  iiiculation  ;iiul  \\:i\c  Ikcoiiu-  iiKapsulatccl 
l>\  tin  sm  roiiiulinii  tissiu-,  ;iiul  w  Inn  rluv  h;i\c*  ceased  growing  and  ha\e 
btjiiin  to  rti;iiss.  I  In-  inhltrarioii  may  occur  as  a  solid  mass,  or,  what 
is  more  coinnioii,  as  a  shell  ahoiir  a  tmiior  node  'I'ig.  393).  When  the 
mass  is  soliil  rluii'  is  a  lanullar  ai  raiiucimnr.  In  some  of  these  areas 
of  infiltration  the  connective  tissue  is  not  entirely  lost,  foi  ir  may  he 
identified  after  the  calcareous  material  has  heen  removed. 

Fatty  Degeneration.  Fatty  degeneration  in  myomas  takes  place 
normallN  ,  to  a  certain  degree,  after  pregnancy.  The  degree  of  degenera- 
tion and  suhsequent  ahsorption  corresponds,  m  a  measure,  to  the 
increase  in  size  of  the  tumor  during  the  pregnane)'.  Man\'  of  the  m\omas 
increase  threefold  or  fourfold  during  the  pregnane) ,  only  to  decrease  to 
the  same  degree  after  lahor.  It  is  quite  possible  that  those  tumors  made 
up  largely  of  muscle  cells  respond  more  readily  to  the  stimulus  of  preg- 
nancy than  do  those  made  up  largely  of  Hbrous  tissue.  Fatty  degenera- 
tion may  occur  independent  of  pregnane)'.  It  manifests  itself  macro- 
scopically  by  the  presence  of  yellowish  areas  within  the  tumor.  The 
fat  ma)'  be  absorbed  and  the  tumor  become  reduced  in  size,  or  lique- 
faction ma)'  occur  with  or  w-ithout  a  complicating  hemorrhage  and 
c)stic  formation. 

Necrosis. — If  the  lumen  of  a  vessel  becomes  occluded  the  nutrition 
of  the  tumor  becomes  disturbed.  This  ma)'  take  place  from  changes 
within  the  vessel  itself,  r.  g.,  endarteritis,  particularly  in  individuals 
of  advanced  age.  In  necrosis,  occurring  immediateh'  after  labor,  it 
is  probable  that  the  vessels  are  occluded  b)'  the  contraction  of  the  wall 
of  the  uterus,  or  b)'  the  extension  of  thrombosis  from  the  placental  site. 
Twisting  of  the  pedicle  in  pedunculated  tumors  or  of  the  entire  uterus 
are  causative  in  rare  instances.  When  a  submucous  tumor  is  being 
expelled  from  the  uterus  the  contracting  fibers  gradualh'  shut  off  the 
blood  suppl)',  and  an  infected  thrombosis  ma)'  then  result  and  produce 
the  accident.  Here,  too,  an  obliterating  arteritis  has  been  noted.  These 
arterial  changes  seem  to  be  particular!)'  prominent  in  those  cases  of 
necrosis  which  come  on  in  elderl)'  patients  with  quiescent  tumors. 
The  arteries  of  the  tumor  seem  to  share  in  a  general  wa)',  the  changes 
occurring  over  the  entire  bod)-,  but  those  supplying  the  tumor  become 
affected  before  or  ma)'  be  more  extensive  than  other  vessels. 

Any  of  these  factors  may  cause  necrosis,  or  several  of  them  ma)"  be 
operative  in  the  same  case.  The  central  part  of  the  tumor,  being  the 
least  vascular,  usualh'  suffers  first  in  this  process.  With  the  shutting 
off  or  diminution  of  the  nutrition  bacteria  may  gain  access  and  suppu- 
ration ma)'  be  added  to  the  picture.  The  source  of  the  bacteria  may 
be  the  intestinal  tract  or  the  interior  of  the  uterus  or  the  blood  stream. 
The  necrotic  area,  either  in  itself  or  from  the  suppurative  complication, 
35 


546 


MYOMA  OF  THE  UTERUS 


or  from  necrobiotic  intoxication,  may  lead  promptly  to  the  death  of 
the  patient.  If  the  area  mvolved  is  small,  encapsulation  with  C3^st 
formation  or  with  calcareous  mfiltration  may  result. 

With  partial  obstruction  of  the  circulation  the  areas  of  the  tumor 
best  supplied  with  nutrition  may  exhibit  an  inflammatory  reaction 
which  may  cause  attachment,  notably,  to  the  omentum,  and  the  addi- 
tional nutrition  thus  secured  may  prevent  an  impending  necrosis.  These 
new  attachments  may  become  loosened  when  the  original  circulation 
has  been  reestablished,  or  it  may  remain  as  a  permanent  adhesion. 
The  nutriment  obtained  from  its  new  attachment  may  be  such  that 
its  original  attachment  with  the  uterus  may  become  loosened  and  the 
tumor  become  free  withm  the  abdomen. 

Fig.  394 


Hemorrhagic  myoma  of  the  uterus. 


Hemorrhagic  Degeneration^  (Fig.  394). — Not  infrequently,  particularly 
in  women  beyond  the  menopause,  a  so-called  hemorrhagic  degeneration 
takes  place.  In  these,  extravasated  blood  makes  up  a  considerable  part 
of  the  bulk  of  the  tumor  and  usually  there  is  an  extensive  formation 
of  bloodvessels  (Fig.  395)  with  imperfectly  formed  walls.     Surrounding 

"  Fairbairn,  Jour.  Obst.  and  Gyn.,  Brit.  Emp.,  1903,  xviii,  119. 


s.iRcoM.iroi  s  I)Ia;i:\  i.k  1 1  I().\ 


04' 


rlu-si-  \(.-ssfls  ;iii-  l;im,(  miml>ris  ol  mipci  h  rt  1  \  loinitd  hhioiis  tissue 
masses.  I  he  i\t  i;i\  ;is;ii((l  Mocul  n  ni;ims  iin|)ti  hit  1\  lojmihiicd  iiulih- 
nitfh  ,  tlirtViinii  in  this  ii'j;;ircl  tiom  h(  ini»i  i  ha^i-  into  cli-jic-nc-ratcd  areas 
otdthii  t\ins.  I  l(  iiioi  iha<!,u',  cU-^(  lu  i  a  i(  d  areas  ina\  icmaiii  stationary 
lor  iiulitiiiiir  pii  loils,  ami  auaiii  ma\  (KxK-  the  i.a|)siilc  (bigs.  396  and 
397)  surroiiiulini;  thrm,  (.omini;  m  this  \\a\  to  protiiidr  1)(\  oiid  the 
surface  ot  the  uterus.  In  orhers,  sarcomatous  ehanjics  take  place, 
reslllrin^   in    tumors  ol    rii«;hrlul   mali<i;nanc\-. 

Kk;.  y)S 


Blood  spaces  in  hemorrhagic  degeneration  of  myoma. 

Sarcomatous  Degeneration. — The  change  from  a  slo\vl\-  growing  myoma 
to  a  rapidly  growing  tumor  with  the  microscopic  picture  of  sarcoma  is 
observed  in  1.4  per  cent,  according  to  Noble, ^  or,  accordmg  to  W  inter, - 
in  4.3  per  cent,  of  a  series  of  carefull}'  examined  tumors.  These  figures 
apply,  of  course,  onl\-  to  myomas  which  have  come  to  operation. 
Gebhard^  regarded  these  changes  as  due  to  a  metamorphosis.  He 
beheved  that  he  had  observed  the  change  of  adult  muscle  cells  into 
sarcoma   cells,   and,  indeed,  m\"   own   studies   have   convinced    me    that 


'  Jour.  Amer.  Med.  Assoc,  1906,  xlvii,  1881. 

^  Ztschr.  f.  Geburtsh.  u.  Gynak.,  1906,  Ivii,  8. 

^  Pathologische  Anatomie  der  weiblichen  .Sexualorgane,  Hirzel,  Leipzig,  1899. 


548 


MYOMA.  OF   THE  UTERUS 


this  does   occur,   at  least  in   the   hemorrhagic   myomas.     Be   this   as   it 
may,  sarcomas  frequently  appear  within  myomas,  or  tumors  previously 

Fig.  396 


Hemorrhagic  myoma  perforating  the  uterine  wall  at  X. 
Fig.  397 


The  same  as  Fig.  396,  showing  the  region  of  perforation  on  cross-section. 


MIXED   TlMOkS  or   Till:   ITJ-klS  549 

regarded  as  m\ oiiiatoiis  become  sarcomatous.  W'lietlier  this  comes 
about  tlnou^h  a  iiutaniorphosis,  or  the  sarc(jma  arises  cle-  novo  in  the 
substance  ot  the  m\ oma,  or  the  tumor  was  sarcomatous  from  the  begin- 
ninji.  ma\  not  be  capable  of  proof  in  a  given  instance.  A  reexamination 
o[  the  subject  with  the  use  of  Mallor\'s  myogha  stain  ma\-  give  some 
valuable  information  both  as  to  accurate  (btterential  diagnosis  and  as 
to    the   (]uesfi()n    ot    oniiin    of  tlie   sarcoma. 

Malignant  Myomas.  More  perplexing  still  than  the  preceding  are 
those  mstances  \n  which  myomas  are  said  to  form  metastases.  This 
accident  has  been  recorded  by  competent  observers,  so  that  the  exist- 
ence of  such  a  condition  cannot  be  denied,  though,  as  Gebhard  reluc- 
tantly- admits,  the  occurrence  must  be  ver\-  rare  indeed.  So  rare,  in 
fact,  that  they  are  to  be  regarded  rather  as  pathological  curiosities 
than  ot  practical  interest.  Theoretically,  those  who  assume  a  meta- 
morphosis trom  myoma  to  sarcoma,  regard  this  as  a  middle  stage. 
I  he  microscopic  differentiation  between  the  rapidl\'  growing  m\omas 
and  the  sarcomas  is  sometimes  so  difficult  that  we  have  a  right  to 
question  all  but  the  most  thoroughly  trained  observers.  Here,  too, 
Mallor^'s  mA-oglia  stain  ma)'  shed  a  new  light. 

Mixed  Tumors  of  the  Uterus.'— It  is  questionable  whether  true  mixed 
tumors  have  been  observed  in  the  uterus.  A  few  chondromyomas  and 
osteomyomas  have  been  reported,  but  none  of  them  with  sufficient 
detail  to  permit  of  accurate  judgment.  Dermoids  and  embryomas 
occur  in  the  region  of  the  uterus,  in  the  ovar\-,  or  in  the  retro-uterine 
space,  and  these  at  times  suppurate  and  break  through  into  the  uterus. 
It  is  possible  that  complications  in  tumors  so  situated  have  been  mis- 
taken for  tumors  occurring  primarily  in  the  uterus.  In  some  of  the 
older  recorded  cases  the  diagnosis  was  made  on  the  extrusion  of  der- 
moidal  particles  from  the  uterus. 

Frequency. — Statistics  of  autopsies  made  on  females  over  thirt\- 
years  ot  age,  show  myomas  present  in  from  12.6  f Williams)  to  20  per 
cent.  (Boyle)  of  all.  These  include  all  cases  in  which  a  tumor  can  be 
detected  at  autopsy.  Many  of  these  do  not  exceed  a  pea  in  size  (Fig. 
398),  and  may  easily  go  undetected  unless  the  uterine  wall  is  incised. 
These  statistics  may  be  accepted  as  correct  from  the  pathologist's 
point  of  view,  but  erroneous  conclusions  result  when  the\-  are  applied 
to  questions  of  therapeutics  and   practical  diagnosis. 

Obvioush-  enough,  such  a  large  percentage  of  women  do  not  suffer 
inconvenience  from  myomas.  The  difficulty  is  in  determining  which 
are  of  clinical  importance  and  which  are  not.  It  ma\-  safelv  be  said 
that  the  small  dense  ones   composed   almost  wholly  of  fibrous  tissue, 

^  Herb,  Surg.,  Gyn.,  and  Obst.,  1910.  x,  463. 


550 


MYOMA  OF  THE  UTERUS 


Fig.  398 


situated  within  the  uterine  wall  (Fig.  398)  or  beneath  the  peritoneum 
are  innocent.  These  are  accidental  discoveries  at  autopsy  or  during 
operation  for  other  diseases.  Unfortunately  it  is  sometimes  impossible 
to  judge  whether  or  not  a  tumor,  small  at  the  time  of  observation,  will 

later  assume  clinical  importance  or  not.  The 
age  of  the  patient,  the  structure  of  the  tumor 
and  its  situation  usually  make  an  accurate 
judgment  possible.  A  revision  of  our  statis- 
tics along  these  lines  is  much  to  be  desired. 
Myomas  which  are  actively  growing  or 
have  attamed  some  size  never  fail  to  produce 
discernible  clinical  signs.  Innocent  myo- 
mas, when  this  class  of  tumors  is  in  mind, 
are  as  rare  as  innocent  gallstones.  This 
fact  makes  it  particularly  desirable  that 
the  small  innocent  class  be  separated  from 
their  more  formidable  congeners.  A  failure 
to  do  this  has  resulted  in  the  removal  of 
many  innocent  uteri.  Of  this  fact  every 
pathological  laboratory  abounds  in  mute 
testimon}^  Surgeons  rather  than  pathol- 
ogists must  determine  the  frequency  of 
clinically  important  myomas. 
Biological  Changes. — Influence  on  Fecundity. — The  fecundity  of  myo- 
matous women  is  reduced,  on  the  average,  nearly  fourfold,  on  account 
of  changes  in  the  mucosa  and  malpositions  of  the  canal.  Many  con- 
ceive and  then  abort,  due  to  the  changed  mucosa  or  to  the  inabihty 
of  the  myomatous  wall  to  expand,  or  to  secondary  changes  in  the  tumor. 
If  the  product  of  conception  is  lodged  in  an  inaccessible  part  of  a  tor- 
tuous uterine  canal  the  expulsion  may  be  incomplete  and  sepsis  may 
result.  If  the  tumor  is  low  down  in  the  pelvis  it  may  interfere  with  the 
advancing  head.  The  rapid  growth  of  the  tumor  incident  to  the  preg- 
nant state  may  be  so  great- as  to  cause  grave  symptoms  from  pressure. 
The  rate  of  growth  during  pregnancy  varies,  but  bears  a  general  relation 
to  the  amount  of  its  blood  supply  and  to  the  proportionate  quantity 
of  muscle  fibers  the  tumor  contains,  being  greater  the  nearer  the  tumor 
approaches  a  pure  myoma.  As  an  approximate  estimate,  it  may  be 
said  that  the  tumor  will  quadruple  during  the  course  of  the  pregnancy. 
If  the  tumors  are  subserous,  they  ascend  with  the  growing  uterus  and 
interfere  but  little  with  labor.  If  pregnancy  takes  place,  the  probable 
effect  must  be  judged  from  the  size  and  location  of  the  tumor. 

Influence  of  the  Menopause. — In  the  past  the  effort  has  been  made  to 
tide  the  woman  over  until  the  menopause,  which  event  was  supposed 


Small  intramural  myoma. 


iiEMokkii  n.i.  IS  MYOMA  nr  rill-:  i  ri-:j(i  s  't'A 

to  icIuNc-  luinoi  I  luitic  ;iiul.  in  fact,  it  ti((|iuiit  1\  clul  so.  I  In-  ni\<Miia 
iisiialh  |>artui|Kiiis  in  flu-  chan^fs  to  which  the  ninital  orj^ans  are 
suhjict  .11  this  tiiiif.  I  he-  txact  facts  iiiuici  l\  in^;  these  changes  arc 
jireatl\    in  need  of  reiieweil  exaniination. 

Changes  in  Other  Organs.  Ovaries  and  Tubes.  I  he  ovaries  are  fie- 
ciiunth  thi-  siat  of  inf]ammator\  and  cystic  changes,  or  of  cwstoma.s. 
riiey  are  fret|uintl\  stuildecl  with  folhcles  with  thick  walls;  the  tunica 
is  iiuich  thickeiud  ami  tin-  entire  o\ar\'  is  intensel)'  sclerotic.  The 
intei-iclationship  is  not  understood. 

The  Heart.'  Ihe  frequency  of  cardiopathies  in  m\omas  has  been 
repeatedly  noted,  and  must  be  recognized  as  one  of  the  grave  features 
of  the  disease.  1  he  directly  associated  lesion  is  usually  degeneration 
of  the  heart  muscle  itself.  Pressure  upon  large  vessels  thus  causing  an 
increased  amount  of  work  has  been  thought  to  e.xplam  its  occurrence, 
but  the  cardiac  disturbances  are  quite  as  frequent  when  the  tumors 
are  of  such  a  size  and  location  as  to  exclude  the  effect  of  pressure. 
Other  explanations  are  that  a  toxin  produced  by  the  muscle  tissue 
in  the  tumor  gives  rise  to  the  effect  upon  the  heart  muscle,  or  that  the 
influence  is  reflex,  the  expanding  uterus  causing  disturbance  through 
the  sympathetic  system.  Ihe  fact  that  other  diseases  in  the  pelvis 
are  accompanied  by  similar  disturbances  in  the  heart  seems  to  add 
probability  to  the  last  explanation  in  some  cases;  when  the  heart 
lesions  are  organic,  however,  it  certainly  does  not  hold.  Whatever  the 
relationship  may  be,  the  condition  of  the  heart  must  be  considered  a 
part  of  the  clinical  picture  of  niAoma,  and  must  be  taken  into  account 
in  prognosis. 

Symptoms. — \\  hen  the  anatomy-  and  pathology  of  the  uterine  m\oma 
are  kept  in  mind,  the  clinical  manifestations  are  easily  understood.  The 
symptoms  are  not  pathognomonic,  for  the}'  can  all  be  simulated  by 
other  pelvic  conditions.  There  is  a  triad  of  symptoms,  however,  which 
suggest  m\'oma,  though  physical  examination  alone  can  demonstrate 
the  disease.     These  are  hemorrhage,  pain,  and  pressure. 

Hemorrhage. — Loss  of  blood  in  myoma  depends  primarih^  on  the 
location  of  the  tumor.  Dudley"  expresses  this  relation  terseh"  in  the 
following  words;  "The  closer  to  the  uterine  mucosa,  the  greater  the 
hemorrhage;  the  nearer  to  the  peritoneum,  the  less  the  hemorrhage; 
hence  hemorrhage  is  almost  invariable  with  the  submucous  variet\', 
less  severe  but  very  common  with  the  intramural,  and  usualh-  slight 
or  absent  in  the  subperitoneal." 

'  For  an  excellent  resume  see  Fleck,  Arch.  f.  Gyniik.,  1904,  Ixxi,  258. 
-  The  Principles   and    Practice  of  Gynecolog}-,  Lea  &  Febiger,  Philadelphia,  5th   ed., 
1908. 


552  MYOMA  OF  THE  UTERUS 

The  type  of  hemorrhage  varies  grea.t\y.  There  may  be  mereh'  a 
prolongation  of  menstruation  to  seven,  ten,  or  fourteen  da^'s.  The 
bleeding  at  the  beginning  ma}'  be  severe,  and  after  a  few  davs  become 
less,  and  continue  then  for  a  period  as  a  slight  bloody  discharge,  or 
there  may  be  several  free  davs  which  are  followed  by  a  renewed  dis- 
charge of  blood.  This  latter  type  of  hemorrhage  is  usually  associated 
with  myoma  only  indirectly,  inasmuch  as  it  is  caused  by  the  changes 
in  the  pelvic  organs  as  a  whole,  and  may  occur  regardless  of  the  location 
of  the  tumor.  The  hemorrhage  may  have  no  relation  to  the  time  of 
menstruation,  and  continue  for  indefinite  periods.  In  submucous  m3'omas 
it  may  be  so  profuse  as  to  threaten  the  patient  with  exsanguination. 

The  character  of  the  blood  may  differ  but  little  from  the  normal 
flow;  It  is  usually  fluid,  often  serosanguinous,  particularly  as  the  flow 
is  subsiding,  and  frequently  it  is  brownish  and  granular,  particularly 
when  the  mucosa  is  encroached  upon.  When  necrosis  occurs,  the  dis- 
charge mav  be  gra}'ish,  greenish,  or  blackish,  and  possess  an  off"ensive 
odor. 

The  cause  of  the  bleeding  was  for  a  long  time  ascribed  to  the  inflamma- 
tory processes  in  the  endometrium,  but  this  is  seldom  present  fClark,^ 
Cullen).-  The  usual  changes  leading  to  hemorrhage  are  as  follows: 
As  the  tumor  encroaches  upon  the  endometrium,  the  vessels  become 
compressed  and  their  walls  atroph}'  from  pressure;  m  addition,  the 
tumor  constitutes  a  mechanical  obstruction  to  the  uterine  circulation 
and  raises  the  pressure  within  the  weakened  vessels  (Clark).  Necrosis 
of  the  capsule  of  the  tumor,  where  the  large  venous  sinuses  are  found, 
accounts  for  some  of  the  sudden  and  extensive  hemorrhages. 

In  mam^  uteri  aff"ected  with  myomas,  chiefly  of  the  submucous 
variety,  the  endometrium  undergoes  distinctive  structural  changes. 
The  uterine  glands  proliferate  and  may  extend  into  the  muscle,  or  at 
least  impinge  upon  it,  and  the  mucosa  as  a  whole  is  much  thickened; 
in  short,  the  endometrium  remains  constantly  in  a  premenstrual  state. 
This  condition  gives  rise  to  that  kind  of  hemorrhage  in  which  there  is 
simply  a  prolongation  of  the  menstrual  flow  without  a  change  in  type. 
In  other  cases  there  is  a  more  active  proliferation  of  the  glands,  which 
also  leads  to  a  thickening  of  the  endometrium,  but  causes  profuse 
hemorrhage  at  the  time  of  menstruation  or  during  the  interval. 

Conditions  like  this  are  often  classed  as  adenocarcinoma  of  the  fundus 
complicating  fibroma.  Some,  no  doubt,  are  such;  others,  while  morpho- 
logically carcinomas,  are  relatively  benign,  for  the}^  exist  many  years 
without   malignant   manifestations.      These    conditions    resemble    those 

^  Johns  Hopkins  Hosp.  Bull.,  1899,  x,  11. 

2  Kelly  and  Cullen,  Myomata  of  the  Uterus,  Saunders,  Philadelphia,  1909. 


PRESSCK/:  /A    MYOM.I  oi    THE  CTERUS  553 

louiul  in  tlu  ;iili  nnm\  oiiKis  ixcipi  th;it  tlu-  tiiiiKu  is  ciiciinistril>t.tl 
;iiul  wirliDur  rlu-  |mstiue  ot"  jjlaiuls,  aiul  rlic  cluinncs  in  the  mucosa 
art-  limited  in  txtint.  Most  writtis  comnunt  on  the  fact  that  the 
fxistcnct*  ot  thfsi'  supposedly  tundal  carcinomas  prior  to  pcjstoperative 
examination  was  not  sus|Hctril.  I  his  aloiu-  should  cause  hesitation  in 
classmti  rluni  as  mali<;nanr.  I  lu-  itlari\i-  heni^nanc\'  of  this  ^hindular 
prolitiiarion  should  In-  leco^m/.ed,  hecause  when  it  occurs  with  cir- 
cumsciilud  m\ omas  a  conservative  operation  is  still  permissible.  When 
the  tumor,  touether  with  the  hyperplastic  eiulonurritis  'for  if  can  he 
recoiiiu/ed  hy  ahdonunal  hysterotomy ),  is  remo\ed,  a  permanent  result 
is  obtained;  bur  when  this  t\pe  of  endometrium  occurs  with  a  diffuse 
increase  ot  the  ni\()merrium  ^  atieiiomyoma ),  local  remoNal  cannot  be 
practised. 

Discharge  other  than  hemorrhages  may  take  place  from  a  myomatous 
uterus.  Ihis  may  result  from  infection,  or  there  ma\'  be  an  increased 
mucous  secretion,  w  Inch  disajipears  when  the  offending  tumor  is  removed. 
1  he  discharge  may  be  watery,  though  seldom  so  watery  as  in  a  case 
reported  by  Drope,  in  which  a  clear  discharge  which  had  persisted  for 
a  number  of  years  was  shown  after  operation  to  be  due  to  a  lymphatic 
condition  of  the  tumor. 

Pain. —  The  congestion  due  to  displacement  or  to  pressure  upon  the 
veins  may  give  rise  to  pain,  which  is  usually  a  sense  of  weight  or  aching 
in  the  back  and  groins.  It  ma\'  fluctuate  with  menstruation  or  have 
nothing  definitely  characteristic.  The  pain  which  suggests  the  presence 
of  a  m^oma  is  cramp-like,  simulating  the  expulsive  pains  of  labor,  to 
which  it  is,  in  fact,  analogous,  for  it  is  produced  hy  the  contractions 
of  the  hyperplastic  uterine  walls  in  an  effort  to  expel  the  tumor.  This 
view  is  substantiated  b\'  the  fact  that  when  a  painful  intramural  fibroid 
becomes  submucous  or  subserous  the  pains  cease  (\  eit).^  This  pheno- 
menon was  formerly  observed  with  frequency  when  myomas  were  allow'ed 
to  pursue  their  natural  course.  Pain  severe  and  constant  is,  however, 
sometimes  observed.  This  is  believed  to  be  due  to  the  expansion  of 
the  uterine  tissue  b}'  the  growing  tumor,  and  occurs  especially  in  those 
located  near  the  cornu.  \  ery  small  tumors  in  this  situation  may  be 
the  cause  of  distressing  pain. 

Pressure. —  1  he  size  of  the  tumor  alone  does  not  always  explain  the 
pressure  symptoms  produced.  A  comparatively  small  tumor  pressing 
upon  the  bladder  may  cause  frequent  urination,  or  one  pressing  upon 
the  rectum  may  there  cause  disturbance  of  function.  When  the  tumor 
becomes  so  large  that  the  pelvis  accommodates  it  with  difficulty,  constant 
severe  distress  results  from   direct  pressure  and  from   reflex  irritation. 

Handbucli  der  Gyniikologie,  Bergmann.  \\  iesbaden,  1897,  Bd.  ii. 


554  MYOMA  OF  THE  UTERUS 

When  the  tumor  is  raised  above  the  pelvic  brim,  the  disturbances  are 
alleviated.  It  is  only  rarely  that  serious  results  are  produced  by  press- 
ure. The  ureters  may  be  compressed  in  rare  instances;  the  function 
of  the  rectum  is  more  apt  to  be  seriously  interfered  with,  but  none 
of  these  reach  a  serious  degree  unless  the  shape  and  position  of  the 
tumor  are  such  that  it  cannot  rise  out  of  the  pelvis,  and  the  continuous 
growth,  therefore,  compresses  all  the  soft  parts.  When  this  condition 
exists  the  tumor  is  said  to  be  incarcerated. 

Reflex  Disturbances. — Among  the  indirect  effects  certain  cardiac  dis- 
turbances are  most  frequent.  These  are  palpitation,  a  general  sense 
of  uneasiness,  headache,  digestive  disturbances,  and  dyspnea,  all  of 
which  are  due  to  uterine  disturbance,  resulting  from,  but  not  neces- 
sarily directly  dependent  upon,  the  tumor.  This  is  shown  by  the  fact 
that  these  may  be  present  in  the  absence  of  any  pelvic  symptoms 
suggestive  of  myoma;  but  in  the  absence  of  other  causes  they  should 
lead  to  examination  for   myoma. 

As  the  anatomy  of  myoma  indicates,  the  physical  findings  will  vary. 
The  uterus  is  usually  lobulated  and  painless  and  more  or  less  deformed 
by  hard  masses,  depending  upon  the  number,  size,  and  situation  of 
the  tumors.  It  is  circumscribed  and  movable,  unless  wedged  in  by  the 
borders  of  the  pelvis  or  bound  by  adhesions. 

Diagnosis. — The  presence  in  the  pelvis  of  a  dense  tumor  continuous 
with  or  connected  to  the  uterus,  smooth,  nodular  or  bosselated,  mov- 
able without  pain,  is  characteristic  of  myoma.  In  some  instances 
the  tumor  may  enlarge  the  uterus  equally  in  all  directions;  occasionally, 
when  cystic  or  edematous,  it  may  be  soft;  when  the  seat  of  secondary 
changes,  it  may  be  painful;  when  compHcated  by  periuterine  inflamma- 
tion, it  may  be  both  painful  and  fixed.  Easy  as  the  diagnosis  usually 
is,  it  may  be  difficult  in  the  face  of  complications,  and  a  detailed  differ- 
entiation may  then  be  necessary. 

Differential  Diagnosis. — Some  of  the  points  of  differentiation  from 
conditions  which  may  be  mistaken  for  myomas  follow. 

Pus  Tubes. — When  large  pus  tubes  have  passed  the  acute  stage  and 
the  tenderness  and  fever  have  subsided,  the  pelvic  pain  and  prolonged 
bleeding  at  menstruation  lead  to  the  suspicion  of  myoma.  The  dis- 
tended tumors  and  associated  organs  adherent  to  the  uterus  form  a 
mass  in  the  pelvis  which  frequently  misleads  the  examiner.  The  brief 
duration  of  the  metrorrhagia  and  the  attendant  pelvic  pain  should 
arouse  suspicion  of  pus  tubes,  and  the  demonstration  of  a  fixed  mass 
incapable  of  being  completely  outlined  by  bimanual  examination  should 
shield  from  error. 

Ovarian  Cyst. — Large  myomas  smooth  in  outline  may  simulate  ovarian 
cysts.     When   located    beside   or   behind    the  uterus,  particularly  when 


/•RJ.CX.IXCY   .l\n   M)'(fMt  <)l    Till-    I   I'IRl'S  555 

attiitlud  onK  l>\  ;i  loiiR  pi-dnK ,  the  dillci  t  nii;iti<)n  ni;i\  l>c  difHtiilr. 
Tin-  ;iir;itti  il(.iisit\  ot  tin  in\<>ma  and  the  movfiiient  inipartt-d  to  it 
wlu'ii  tin-  uttrus  is  moxtd  maki  a  ditlc  icnriation  possildc.  Large 
nnonias,  wlu-ii  occuin  in^  tlu  aluloimn,  laii,  on  the  other  hand,  be 
dittViTiuiati-d  h\  tlu-  niovcnuni  mipaiti-d  to  tlu-  utc-ms  \slun  tlu- 
tiiiiu)!  is  iiio\i-d.  ill  tlu  lar^c- c\stic  in\()iiias  this  is  the  (jnl\'  leliahle 
siun,  uhili-  in  tlu-  solul  niNomas,  the  consistency  of  the  tumor  f^ives 
aildiriona!   f\  uk-ncf. 

Orlu-i  runiois  of  rlu-  ovary,  noraM\  tlu  solid  ones,  may  present 
dirticulrics  which  can  be  overcome  only  by  a  careful  study  of  their 
relation  to  the  uterus.  Dermoids  and  teratoid  tumors  of  the  ovar\'  ma\- 
present  difHculties.  Intraligamentous  m\ omas,  b\  their  situation,  their 
dinsir\  ,  and  miniobilitw  are  easily  differentiated  from  ovarian  tumors. 

Pregnancy.  Myomas  when  enlarging  the  uterus  uniformh',  and 
particularl\-  when  degenerated,  may  cause  a  close  resemblance  to  the 
pregnant  uterus.  The  secondar}'  signs  of  pregnane)-  are  absent  but 
the  cervix  may  be  softened  and  the  patient's  imagination  ma\-  supply 
the  subjective  signs  of  pregnancy.  The  sudden  passage  of  the  uterus 
into  the  abdomen  may  imitate  rapid  development,  a  delusion  which 
observation  over  a  number  of  weeks  alone  will  rectif\-.  Secondary 
changes  within  a  myoma  may  simulate  rapid  growth.  When  withm 
the  pelvis  myomas  are  denser  than  a  pregnant  uterus,  and  the  supra- 
vaginal softening  is  not  found,  neither  is  the  cervical  softening  so  great 
as  in  pregnancy,  although  this  sign  may  be  hard  to  estimate  in  a  scarred 
and  lacerated  cervix.  When  the  myoma  occupies  the  abdomen,  tetal 
sounds  are  absent,  as  are  the  rhythmic  contractions  of  the  uterus. 

Menstruation  is  usually  present  in  myoma  and  often,  of  course, 
increased  in  duration.  The  question  of  hemorrhage  complicating  preg- 
nancy, or  the  presence  of  fibroids  at  or  shortl}-  after  the  menopause, 
often  interject  annoying  perplexities.  In  such  cases  the  physical  exami- 
nation, as  above  detailed,  must  be  depended  upon.  The  social  state 
must  not  be  allowed  to  bias  the  judgment,  for  pregnant  uteri  in  the 
widowed  and  unmarried  are  often  presented  as  probably  myomatous, 
even  with  the  supposititious  history  of  exaggerated  menstruation. 

When  myoma  is  complicated  by  pregnancy,  the  diagnosis  is  difficult. 
If  the  myomas  are  subserous,  the  physical  findings  are  those  normal  to 
a  pregnant  uterus  the  size  of  uterus  and  tumors  together.  The  dense 
nodular  projections  on  the  summit  of  the  tumor  are,  however,  char- 
acteristic of  m\oma.  In  the  interstitial  variety  the  diagnosis  of  preg- 
nancy must  depend  upon  observation  of  the  early  signs.  It  the  tumors 
are  large  or  multiple,  and  involve  the  entire  wall  of  the  uterus,  diagnosis 
in  the  earl\-  months  cannot  be  made;  but  in  such  cases  the  completion 
of  pregnane)-  is  impossible,  and  the  problem  resolves  itself  into  one  ot 


556  MYOMA  OF  THE  UTERUS 

fibroma,  the  pregnancy  being  ignored.  Myomatous  uteri,  when  the 
tumors  are  subperitoneal,  are  often  able  to  accommodate  themselves 
remarkably  to  the  growing  fetus  and  complications  with  pregnancy 
must  not  be  regarded  with  too  great  apprehension. 

Submucous  myomas  may  simulate  impending  abortion  on  account  of 
the  profuse  hemorrhage  and  the  presence  of  a  mass  within  the  cavit}' 
of  the  uterus.  The  history  may  be  of  value  in  diagnosis,  and  digital 
examination  of  the  interior  of  the  uterus  makes  the  differentiation 
easy.  Syncj^tial  masses  may  present  signs  of  sloughing  myoma,  but 
the  soft,  mottled,  reddish-gra}^  mass  is  unlike  a  degenerating  myoma, 
and  it  is  necessary  to  resort  to  the  microscope  to  obtain  distinctive 
evidence. 

Finally,  the  inspection  of  the  myomatous  uterus  through  an  abdominal 
incision  may  leave  some  doubt  as  to  the  question  of  pregnancy.  The 
cystic  degenerated  myoma  lacks  the  softness  of  pregnancy,  and  in  the 
latter  condition  the  tubes  and  round  ligaments  come  off  from  the 
highest  part  of  the  uterus,  while  in  myoma  the  fundus  bulges  upward 
from  the  point  of  tubal  attachment.  This  is  particularl}'  distinctive 
when  the  tubes  are  located  at  different  points  relative  to  the  apex  of 
the  fundus. 

The  question  as  to  justification  of  the  use  of  the  uterine  sound  when 
all  other  means  of  diagnosis  have  been  exhausted,  is  a  matter  of  personal 
opinion.  An  exploratory  incision  is  less  injurious,  since  pregnancy  is 
not  interrupted,  which  is  certain  to  result  if  a  sound  is  used  in  a  preg- 
nant uterus.  It  is  my  opinion  that  if  a  positive  diagnosis  cannot  be 
made,  the  only  alternative  is  to  wait  until  a  diagnosis  is  certain.  Preg- 
nancy will  soon  declare  itself.  In  the  face  of  hemorrhage  vaginal  packing 
may  be  resorted  to. 

The  use  of  the  sound  in  the  non-pregnant  uterus  ma}'  be  permitted, 
though  it  must  be  added  that  to  the  inexperienced  it  gives  but  little 
information  and  may  produce  harm,  while  the  experienced  will  find 
little  use  for  it.  The  tortuosity  of  the  myomatous  canal  causes  the  tip 
of  the  sound  to  impinge  upon  kinks  in  the  canal,  giving  a  false  notion 
as  to  its  depth. 

Rare  Tumors  of  the  Pelvis. — In  rare  instances  the  spleen  has  descended 
into  the  pelvis  and  has  been  mistaken  for  a  myoma.  The  absence  of 
the  spleen  from  its  normal  habitat,  the  possibility  of  replacement,  the 
non-attachment  to  the  uterus,  and  often  the  discovery  of  the  splenic 
notch  should  make  a  differentiation  possible.  Mesenteric  tumors  are 
retroperitoneal,  and  those  attached  to  the  gut  may  simulate  myomas 
of  the  uterus,  but  the  independence  of  such  growths  from  the  uterus 
is  distinctive.  Tumors  attached  to  the  pelvic  wall  are  easy  of  differ- 
entiation. 


SEcoM)  iRY  i)iA:i:M:k.iTi<)\  i\  myumis  ii'u 

Secondary  Degeneration  in  Myomas.  I  In  cK monsniirion  of  rlu- 
l^irsiiu'f  ot  ;i  m\(>m;i  dois  not  ciul  the  tliannosrii  pioMtin,  for  am  of 
rlu-  si'C()iuiar\  ili-;;iiuian<)ns  may  hi-  pit-st-nr.  Asolr  l)onn\  red  iiuiicares 
filenia;  st'initUuruaroii,  an  t-xn-nsivi-  myxomatous  dc^eiurarion  or 
cyst  foiiiiation.  Mon  important  an-  tin-  necroses  anil  malij^nant 
degenerations.  Suppuration  or  necrosis  is  attended  by  c(jnstitutional 
disturbance  and  pain;  dulls  and  hijib  fever  are  not  uncommon.  Kxten- 
si\i  suppurations  ma\'  occur,  bo\\e\er,  without  notable  constitutional 
diaiiiiis.  Diffuse  abilommal  pain  is  fre(|uent,  and  \\  hen  the  wall  of  rhe 
uterus  IS  approachin<j;  rupture  from  a  hemorrhajiic  myoma,  localized 
tenderness  may  he  present.  Malignant  dej^eneration  is  suf^^^sted  b\' 
rapid  enlarsiemenr  and  by  the  presence  of  multiple  nodules  of  pinker 
hue  than  the  remainder  of  the  rumor.  \  aiiations  m  consistency'  in 
different    leuions   of  rhe   rumor  are  always  suspicious. 

Prognosis.  Non-operative.  Left  ro  their  own  course,  a  certain  per- 
centage of  myomas  directl)'  cause  rhe  death  of  rhe  patient.  This  is 
brouiiht  about  by  hemorrhage,  by  pressure  upon  neighboring  organs 
'rectum,  bladder,  ureters),  by  degenerative  changes,  either  necrotic 
or  malignant,  and  indirectly  by  reducing  the  general  resistance  of  the 
patient  so  that  she  more  easily  succumbs  to  intercurrent  diseases. 
The  elusiveness  of  this  latter  factor  makes  impossible  even  an  approxi- 
mate estimate  of  the  percentage  of  deaths  due  primarily  to  m\oma. 
Prom  the  examination  of  a  large  series  of  recent  statistics,  it  appears 
that  the  mortality  of  untreated  fibromas  is  at  least  5  per  cent,  of  all 
patients  whose  tumors  have  produced  clinical  symptoms.  \\'inckel 
places  the  mortality  at  10  per  cent. 

The  manner  in  which  a  m\oma  ma\'  cause  death  is  not  generalh' 
understood,  and  for  this  reason  is  usually  overlooked  as  an  actual  cause 
of  death.  Hemorrhage  is  probably  the  least  frequent  cause,  but  figures 
prominenth'  in  the  statistics  because  the  condition  is  obvious.  Peri- 
tonitis from  necrosis  or  infection  is  responsible  for  a  large  number  of 
deaths,  hut  is  frequently  overlooked.  Necrosis  of  the  rectum  or  bladder 
with  subsequent  infection  of  the  tumor  is  a  frequent  cause.  Septicemia 
from  infection  of  an  exposed  submucous  myoma,  in  the  process  of 
extrusion,  is  one  of  the  more  common  causes.  This  may  be  associated 
with  abortion  or  labor  at  term,  so  that  the  actual  cause  of  death  is 
wrongly  ascribed  to  obstetrical  accidents.  Diseases  of  the  heart  seldom 
appear  as  the  immediate  cause  of  death,  bur  rhey  figure  prominenrh' 
in  the  fatality  of  intercurrent  diseases  or  in  the  operative  mortality 
when  deferred  radical  treatment  has  been  instituted.  -V  more  careful 
estimate  of  the  mortality  in  untreated  cases  is  desirable,  that  we 
may  better  determine   the  justification   of  any    plan   of  treatment  and 


558  MYOMA  OF  THE  UTERUS 

particular!}'  of  operation  in  early  cases  where  neither  great  discomfort 
nor  immediate  danger  to  life  exists. 

In  estimating  the  prognosis  of  myomas  untreated,  it  cannot  be  too 
strongly  insisted  upon  that  the  percentage  should  be  figured  upon  the 
basis  of  the  number  of  those  which  give  clinical  symptoms.  Until 
this  is  done,  no  accurate  statistics  can  be  accumulated. 

Treatment. — Conservative. — There  is  no  conservative  treatment  for 
myoma  of  the  uterus.  The  use  of  drugs  and  electricity  has  no  place 
in  modern  therapeutics.  Their  use  should  be  discouraged,  for  they 
give  a  false  sense  of  securit}^  to  the  practitioner,  delude  the  patient, 
and  delay  the  institution  of  proper  treatment.  The  mortality  from 
so-called  conservative  methods  is  unquestionably  greater  than  is  that 
from   radical  operation. 

Palliative. — Treatment  for  the  control  of  symptoms  is  justified 
when  for  any  reason  the  removal  of  the  tumor  is  contraindicated. 
Hemorrhage  is  the  condition  most  often  calling  for  palliative  treat- 
ment. Extreme  anemia  or  co-existing  disease  which  would  make  the 
operation  dangerous  justifies  palliative  treatment  while  the  patient 
is  being  resuscitated.  I  purposely  omit  the  mention  of  the  use  of 
palhation  for  those  patients  who  refuse  curative  treatment  on  their  own 
judgment.  When  palliative  treatment  is  indicated,  curative  treatment 
is  indicated.  Any  contraindication  which  may  be  remedied  by  palli- 
ative treatment  should  obtain  onh^  until  it  can  be  removed,  and  then 
curative  treatment  should  be  instituted.  The  failure  to  observe  this 
rule  has  allowed  complications  to  multiply  until  the  operative  mortality 
has  become  higher  than  the  nature  of  the  disease  warrants. 

What  shall  be  regarded  as  indication  for  operative  treatment  of 
fibroids  of  the  uterus  still  has  no  definite  answer  other  than  to  observe 
the  general  principle  (which  is  supported,  I  believe,  by  the  consensus 
of  opinion  in  this  country,  and  in  which  I  concur)  that  when  a  fibroma, 
because  of  its  size,  its  location,  or  physical  condition,  becomes  a  menace 
to  the  health  or  life  of  the  patient,  it  should  be  removed. 

Many  fibroids,  let  it  be  repeated,  cause  no  symptoms;  and  when 
such  are  found  in  the  course  of  treatment  of  other  conditions,  in  which 
they  in  no  wise  play  an  active  part,  there  is  no  reason  for  their  removal. 
On  the  other  hand,  many  fibroids  cause  reflex  disturbances,  especialh' 
of  the  heart,  before  the  local  pelvic  symptoms  have  occurred;  in  these 
cases  removal  of  the  tumor  is  justified.  There  still  remains  to  be  con- 
sidered the  likelihood  of  small  tumors  becoming  large  enough  to  cause 
serious  trouble  in  after  life  and  demanding  operations  when  the  patient 
is  less  able  to  withstand  the  procedure. 

Among  such  may  be  included  those  tumors  which,  without  immediately 
menacing  the   life  of  the   patient,   cause   discomfort,   such   as   increase 


r.ii:i\.ti.  iiYSTiiREcroMY  i\  myomi  or  riii:  i  teris       :..v.i 

ot  the  nunsMiKil  l]i)\s,  si\  in-  iKiikiiilu-,  .mii()\  in;;  Inn  not  alaiiinnj; 
piissuii  .s\  niptoms,  ;iiul  rctVmil  ilist  iii  l);iiH-c-.s.  \\  lu-rlu-i"  or  not  these 
shall  hf  siihiictcd  to  o[Hrati\f  tnatincni  must  citpciul  upon  individual 
conditions  ami  tin-  skill  of  tlu-  ojxiatoi.  1  would  (.-xpifsslN'  exclude 
trom  sui^ica!  considi  ration  those-  small  tumois,  iisimlh  i-ntmU  hhtous 
in  structure,  tlu-  si/i-  ol  a  pianut  or  ha/elnut  oi  e\en  larf^er,  shovvinf; 
no  hypertropin  of  the  utirim  muscle,  which  Hmiie  so  largely  in  post- 
mortem statistics.  I  luic-  is  no  jirool  that  these  timiois  ever  attam 
clinical  siuniHcance.  I'oi  timately,  in  practice  the  (iiiesrion  ot  operative 
indication  is  relatnely  simple. 

In  the  maiorit\-  of  cases  when  the  rumors  aie  hrst  seen  the  symptoms 
are  such  that  the  life  of  the  patient  is  menaced  to  a  greater  degree  by 
the  continuance  of  the  fibroid  than  h\  the  mortality  of  the  operation; 
the  operative  risk  is  justified  to  rescue  the  patient  from  a  lite  ot  suffer- 
ing. It  must  be  particularl>-  emphasized  that  a  patient  ma\-  possess 
a  tumor  and  he  suft'erin^  from  conditions  independent  ot  the  tumor, 
especiall\-  if  it  be  of  the  dense  type,  for  which  surgical  interterence  is 
not  indicated. 

Operative  Treatment.  Two  general  routes  are  available  in  the  opera- 
tive treatment  of  myomas,  the  vaginal  and  the  abdominal. 

Vaginal  Hysterectomy.-  The  radical  cure  of  m\omas  b\-  vaginal  celi- 
otom\-  has  become  unpopular  in  this  countrw  but  is  still  emplo\-ed 
by  a  few  operators;  it  is,  however,  extensively  used  by  European  sur- 
geons. Large  tumors  are  removable  b\-  this  route  only  b\'  morcellement, 
but  tumors  that  fill  the  entire  pelvis  have  been  removed  by  this  pro- 
cedure. Small  intramural  or  subserous  tumors  may  be  enucleated  after 
delivering  the  uterus  through  the  anterior  cul-de-sac.  The  conservative 
operation  is  possible  b}-  the  vaginal  route  only  in  small  tumors  of  ques- 
tionable surgical  importance.  The  advantage  of  this  operation  is  the 
diminished  liability  to  shock  and  infection;  but  these  advantages  are 
more  than  counterbalanced  b\-  the  necessary  inaccurac\-  ot  technique 
and  the  loss  oi  time. 

In  the  distinctly  submucous  tumors  the  vaginal  operation  is  the 
operation  of  choice.  This  is  emphatically  true  of  those  which  have 
become  infected  or  necrotic.  The  procedure  is  as  follows:  The  cervix 
is  exposed  and  grasped  with  the  volsellum  and  drawn  down.  If  the 
tumor  is  within  the  cervix  it  may  be  reached  b\-  dilatation,  or  better 
b\-  splitting  the  anterior  wall  of  the  uterus  after  the  bladder  has  been 
loosened  as  in  vaginal  hAsterectomx';  such  incision,  however,  is  not 
permissible  where  there  is  infection  or  gangrene.  1  he  tumor  having 
been  exposed,  the  capsule,  if  one  exists,  is  split  and  the  tumor  shelled 
out.  Hemorrhage  may  be  checked  b\-  packing  with  gauze  or,  prefer- 
abh-,  b\-  suture;  if  the  anterior  wall  of  the  uterus  has  been  split  it  must 


560 


MYOMA  OF  THE  UTERUS 


be  careful!}'  sutured  to  prevent  hemorrhage.  When  the  fibroid  is  necrotic 
an}'^  incision  in  normal  tissue  should  be  avoided  because  of  the  risk  of 
subsequent  infection.  The  necrotic  tumor  should  be  disinfected  as 
well  as  possible  by  means  of  strong  chemicals,  preferably  20  per  cent, 
formaldehyde.  The  uterus  is  frequently  inverted  by  these  tumors, 
and  care  should  be  taken  not  to  open  into  the  abdomen.  The  point 
of  attachment  of  the  tumor  is  usuallj'  found  distal  to  the  narrowest 
portion  of  the  pedicle,  as  first  pointed  out  by  Emmet.  If  too  large 
to  pass  through  the  vulva,  as  is  frequently  the  case,  it  should  be  reduced 
by  morcellement  to  prevent  injury  to  the  soft  parts. 


Fig.  399 


Moynihan  clamps  used  to  secure  temporary  hemostasis  in  conservative  myomectomy: 
0,  ovary;  T,  tube;  U,  uterus;  BL,  broad  ligament;  LU,  left  ureter;  RL,  round  liga- 
ment; UV,  uterine  vessels;   B,  bladder;   R  and  LU,  right  and  left  ureters. 


Abdominal  Operation. — The  removal  of  myomas  by  this  route  has 
the  advantage  of  being  apphcable  to  tumors  of  all  sizes  and  in  all  situa- 
tions; the  submucous,  when  non-infected,  may  likewise  be  attacked  by 
this  route.  Three  general  plans  of  procedure  are  possible:  {a)  The 
removal  of  the  tumor  alone  with  the  preservation  of  all  or  the  greater 
portion  of  the  uterus  (myomectomy);  {h)  the  removal  of  the  uterus  at 
the  junction  of  the  body  and  cervix  (supravagmal  hysterectomy);  and 
(c)  the  entire  uterus  may  be  removed  fpanhysterectom}^). 

{a)  Myomectomy. — This  operation  has  for  its  purpose  the  preserva- 
tion of  the  sexual  function  of  the  patient.     It  is  the  operation  of  choice 


< 


O 
9) 

(t) 
>> 


jnESO.MYOMi  or  Tin:  rri.kis  .'ci 

wluitsfi  possihK-,  Inir  is  parrnuhii  !\  ;i|)|)Ik  alili-  tn  siilistroiis  tumors, 
ami  It  nia\  In-  usiil  toi  nuiii\  iiitiisnrial  ami  noii-intccri-il  siibmuccus 
tumors.  I' or  tlu-  last  two  \arictits  tin-  o|iirafioii  is  particularU'  apt 
it  dom-  by  tin-  aid  of  temporary  hcmostasis  ( Fiji;.  399).'  Cullen  has 
added  his  testimony  as  to  the  desirability  of  conservative  abdominal 
hysterectomy  when  no  tubal  complication  exists. 

ib)  Si'PRAVACiNAi.  Ampltation  (Plate  II).'-  When  because  from  the 
situation,  size,  or  complexity  of  the  tumor,  or  the  ine.xperience  of  the 
ojierator,  the  conservative  operation  is  not  feasible,  supravaginal  ampu- 
tation IS  the  operation  of  choice.  It  is  preferable  to  panhysterectom\' 
because  it  is  simpler,  has  less  mortalit),^  preserves  the  cervix  and 
the  vagina,  and  secures  a  better  pelvic  floor.  The  argument  of  those 
who  favor  panhAsterectomy,  that  the  cervix,  if  left,  ma\-  subse(juentl\- 
become  carcinomatous,  does  not  justify  the  increased  risk  of  the  com- 
plete operation;  there  are  but  eight  cases'"  in  the  literature  in  which 
this  has  occurred  atter  supravaginal  amputation  for  m\'oma.  In  cases 
where  there  is  cystic  degeneration  of  the  cervix,  the  interior  of  the  cervix 
may  be  removed  with  a  knife  and  the  remainder  left  in  situ. 

(c)  Panhysterectomy. — When  the  cervix  is  involved  in  the  myoma 
or  in  another  co-existlng  tumor,  when  there  is  suppuration  of  the  uterine 
wall,  or  when  the  tumor  has  undergone  rapid  growth,  making  the  exist- 
ence of  a  sarcoma  probable,  the  entire  organ  must  be  removed.  Caution 
must  be  used  here  not  to  mistake  for  malignant  degeneration  some 
obviously  benign  process  such  as  cyst  formation,  edema,  or  pregnanes 


ADENOMYOMA    OF   THE   UTERUS^ 

1  his  class  of  tumors  while  having  much  in  common  with  the  myomas, 
may  well  be  classed  separatel}-,  and  thereby  some  w^ell-marked  differ- 
ences be  emphasized.  Adenomyomas  were  first  described  b\-  Cullen 
in  1906.  They  are  characterized  by  diffuse  hbromatous  thickening  of 
the  uterine  wall  (Fig.  400J,  containing  glandular  outshoots  from  the 
endometrium,  and  covered  b}-  a  shell  of  normal  uterine  muscle.  The 
enlargement  tends  to  involve  all  portions  of  the  uterus,  but  occasionally 
is  confined  to  one  side.  The  m3omatous  tissue  and  the  uterine  capsule 
blend  gradually  with  each  other  and  always  lack  the  loose  fibrous  tissue 

'  Hertzler,  Jour.  Amer.  Med.  Assoc,  1909,  lii,  861. 
-  Ibid.,  1908,  li,  1563. 

•^  Marek,  Monatssch.  f.  Geburtsh.  u.  Gynak.,  191 1,  xxxiv,  :;io. 
^  Currier,  New  ^  ork  Med.  Jour.,  1906,  l.vxxiv,  166. 

"  For   a   complete   presentation    see   Cullen,    Adenomyoma  of  the    Iterus,  Saunders, 
Philadelphia,  1909. 
36 


562  MYOMA  OF  THE  UTERUS 

which  surrounds  the  ordinary  fibroids.  The  glands  are  outshoots  from 
the  normal  mucosa,  and  extend  to  considerable  depths,  but  never 
beyond  the  myomatous  tissue. 

Clinical  Course. — The  uterus  may  be  but  little  larger  than  normal, 
but  it  is  usually  three  or  four  times  the  normal  size,  and  is  generally 
dense.  In  the  majority  of  the  cases  in  Cullen's  series  there  were 
adhesions.  The  menstruation  is  usually  prolonged  and  profuse,  which 
Cullen  ascribes  to  the  increased  area  of  mucosa. 

There  is  usually  pain  at  menstruation,  due,  as  Cullen  thinks,  to  attempt 
of  the  normal  muscle  to  expel  the  myomatous  tissue.  The  prolonged 
bleeding,  the  pain,  the  symmetrical  enlargement,  and  dense  consistency 
make  a  picture  that  may  be  recognized  clinically. 

Fig.  400 


Adenomyoma  of  the  uterus. 

There  is  no  data  on  results  when  untreated.  The  glands  do  not  tend 
to  invade  the  normal  muscle  and  the  tumors  run  a  benign  course.  The 
effect  of  the  menopause  on  these  growths  is  not  known.  It  is  quite 
possible  that  they  have  been  mistaken  for  carcinoma  of  the  fundus 
complicating  fibroids,  of  which  there  is  a  considerable  number  in  the 
literature. 

Treatment. — Supravaginal  hysterectomy  is  the  only  efficient  treat- 
ment, and  it  results  in  a  permanent  cure. 


PREGXJXCr  i.\  MYOMJS 


r>o:i 


MYOMA    OF    THE   ROUND    LIGAMENT' 

I  In-  louiul  ligament,  heinj!;  compostd  of  fibrous  and  muscular  tissue, 
is  subject  to  tumors  like  those  of  the  uterus.  The  intra-abdominal 
portion  of  the  ligament  gives  rise  to  spindle-formed  or  pedunculated 
tumors  which   rarely   become  larj^er  than  a   walnut   '  Kifi.  401  J.     Those 


Myoma  of  the  round  ligament. 

arising  within  the  inguinal  canal  are  prone  to  become  larger.  Their 
density  and  fixation  withm  the  inguinal  canal  are  distinctive.  The}' 
may  be  confused  with  sarcomas  of  the  groin,  and  usually  their  associa- 
tion with  the  cord  must  be  demonstrated  before  their  nature  can  be 
fully  determined.     In  either  situation  simple  excision  is  easih'  practised. 


PREGNANCY   IN   MYOMAS' 

PregnancA'  is  much  less  likely  to  occur  in  the  myomatous  uterus, 
and  when  it  does  occur  may  be  spontaneously  interrupted  or  give  rise 
to  serious  disturbances.  The  disposition  to  sterility  is  influenced  b\' 
the  location  of  the  tumor.  Conception  rareh'  occurs  in  the  submucous 
type,  but  is  little  affected  by  small  subserous  myomas.  On  the  w  hole, 
the  capability  of  the  uterus  to  carry  the  fetus  to  term  is  not  full}-  enough 
appreciated.     If  a  m}omatous  uterus  becomes  pregnant  it  is  presump- 

^  Hirst  and  Knipe,  Surg.,  Gyn.,  and  Obst.,  1907,  iv,  715. 

-  See  Kelly  and    Cullen,  loc.  cit.,  also  Landau,  Myom   bei  Schwangerschaft,  Geburt. 
und  Wochenbett.,  Lrban  and  Schwarzenburg,  Berlin,  1910. 


564  MYOMA  OF  THE  UTERUS 

tive  evidence  that  it  will  be  able  to  carry  it  to  term.     Even  large  tumors 
are  not  incompatible  with  normal  delivery. 

Under  the  influence  of  pregnancy  myomas  undergo  modifications  of 
growth  which  should  be  understood.  They  usually  enlarge  rapidly 
in  pregnancy,  but  regress  correspondingly  during  the  puerperium.  A 
rapid  increase  in  size  of  a  myoma  in  pregnancy,  therefore,  is  not  in 
itself  a  cause  for  alarm. 

The  complications  likely  to  arise  in  the  mj^omatous  uterus  are  abor- 
tion, secondar}^  changes  in  the  tumor  during  pregnancy,  and  obstruction 
to  the  delivery  of  the  child. 

Cause  of  Abortion  in  Myoma. — Hyperemia  and  hypertrophy  of  the 
endometrium,  making  it  an  unsuitable  nidus  for  the  fetus,  inability 
of  the  uterine  cavity  to  expand  because  of  the  rigidity  of  the  walls, 
and  impaction  of  the  myoma  under  the  promontor}^  may  make  the 
continuation  of  the  pregnancy  impossible. 

Degeneration  of  the  Tumor. — Circulatory  disturbance  may  cause 
degeneration  within  the  tumor,  which  is  indicated  by  pain  and  constitu- 
tional symptoms.  It  is  more  common  after  labor  when  the  contraction 
of  the  uterus  tends  to  occlude  the  supplying  vessels  than  during  the 
course  of  the  pregnancy. 

Obstruction  to  Delivery. — The  presence  of  tumors  low  in  the  uterus 
may  obstruct  the  birth  mechanically.  Usually  tumors  which  are  in 
the  pelvis  earl}^  in  the  pregnancy  are  lifted  up  with  the  growing  uterus 
out  of  the  way  of  the  presenting  part  of  the  fetus  during  delivery.  If 
the  pregnancy  goes  on  to  term,  other  obstetrical  accidents  are  numerous, 
such  as  placenta  praevia,  weak  pains,  malpresentation  of  the  fetus, 
particularly  transverse,  uterine  rupture,  inversion,  postpartum  hemor- 
rhages, etc.  The  patient  should  be  informed  of  the  danger  in  a  given 
case  and  be  allowed  m  a  measure  to  determine  the  degree  of  risk  she 
may  see  fit  to  undergo.  The  cardiac  changes  incident  to  pregnancy 
are  added  to  those  characteristic  of  the  myoma. 

Treatment. — The  co-existence  of  pregnancy  and  myoma  is  not  per  se 
an  indication  for  interference.  The  tendency  of  many  operators  to 
proceed  in  all  cases  to  operate  when  this  complication  is  recognized 
is  to  be  deprecated;  each  case,  rather,  should  be  judged  separately 
according  to  its  indications.  Subserous  m3^omas  usually  allow  preg- 
nancy to  proceed  to  term  without  interruption  and  produce  no  complica- 
tions at  labor.  Unfortunately,  the  uncertain  availability  of  suitable  aid 
should  complications  arise  during  labor  often  must  be  allowed  to  weigh 
in  the  decision. 

Removal  of  the  Tumor  Alone. — Vaginal. — Cervical  myomas  when  likely 
to  be  an  obstruction  to  labor  may  be  left  until  the  beginning  of  labor, 
for  if  removed  during  the  course  of  pregnancy  abortion  will  likely  result. 


PRKC..\  IM.Y  l\    MYOM  IS  oO') 

AiU)()\iiN  \i  .  .\I\  ()nu(.t()in\  r;in  lu  |)ti  tmnucl  in  |HcliiiKijhirt(l 
rumors  witliour  tin  iiitii  i  iiption  ot  |>iil:ii;iiu\  ,  hut  in  rlu-sc-  opti  arioii 
is  r;iitl\  iiuliiatfcl,  siiut-  tlu- course  of  prtj;n;iiKy  usualh  is  not  disturhetl 
1\\'  rlH-m.  Iiutisririal  runiois  lia\c  Iniii  icniovcd  i-vt-n  to  openinj^  iiuo 
till-  limine-  ia\it\  without  thi  iiitiiiuption  ol  prc-jiiiancw  Maternal 
nioirahr\  is  less  than  S  per  cent.;  alxtition  took  phui-  in  21  of  <^2  cases. 
( )ii  the  whole,  tin-  operation  ot  ni\()nias  iliiiin^  pn^naiiCN  imist  he 
regarded  as  meddlesome  siiiuer\  .  h)i  usiialh  it  the  tumor  is  so  situated 
as  to  peiiiiit  Its  remo\al  without  the  inteiiu|nion  ot  pr(-};nanc\'  it  would 
cause  no  dfHicidty  it  allowed  to  remain,  and  mi^ht  be  more  safeh'  oper- 
ated after  the  termination  ot"  labor  with  much  less  risk  to  the  child  and 
no   moil'   to   the   mother. 

Removal  of  the  Fetus.-  I  he  ai  tiHcial  production  of  abortion  in  cases 
where  the  <irowth  of  the  uterus  is  disturbed  is  not  justified  because 
(l)  the  location  of  the  fetus  in  the  leniithened  and  tortuous  canal  mav 
be  such  that  it  can  be  reached  with  difficulty  or  not  at  all;  (2)  the  likeli- 
hood of  infection  and  the  other  complications  incident  to  the  disease 
makes  the  operation  a  grave  one.  In  addition  is  the  fact  that  the  patient 
is  not  released  from  her  disease,  and  another  pregnancy  re(juires  a  repeti- 
tion ot  the  treatment.  A  radical  operation  for  the  removal  of  the  tumor 
will  eventually-  be  required,  and  the  mortality  of  radical  operation  in 
pregnancy  will  be  less  than  the  mortality  from  abortion  plus  that  of 
radical  operation  afterward. 

Removal  of  Uterus  and  Tumor.  The  interstitial  fibroids  with  their 
abundant  blood  suppl\-  are  most  likely  to  undergo  rapid  growth  and 
to  suffer  complications.  The  dangers  likely  to  arise  from  a  persistent 
pregnane)-  are  those  due  to  pressure  from  the  combined  size  of  the 
pregnant  uterus  and  the  tumor.  Whether  the  mere  size  of  the  uterus 
will  be  indication  for  operation  cannot  be  certainly  determined  early 
in  pregnane^-,  unless  the  tumor  is  already  so  large  that  the  additional 
size  will  unquestionabl}-  seriousl\-  menace  the  patient.  In  such  instances 
the  pregnancy  may  be  disregarded  in  determining  the  theiapeutic 
indications.  If  the  tumors  are  small  and  slow-growing,  the  pregnanc\- 
may  be  allowed  to  continue,  but  under  close  observation;  for  if  rapid 
growth  takes  place  at  any  time,  operation  may  be  necessar\  .  The 
patient  should  always  be  given  to  understand  that  this  risk  is  present. 
Should  the  growth  be  such  that  the  abdomen  will  be  unable  to  accom- 
modate the  combined  mass  of  fetus  and  tumor,  supravaginal  amputa- 
tion is  the  operation  of  choice. 

If  the  tumor  is  located  in  or  near  the  cervi.x.  Cesarean  section  ma\-  be 
performed  at  term  or  a  radical  operation  may  be  done  earlier.  The  patient 
here  has  the  right  to  a  word,  but  on  the  whole  the  rnortality  of  section 
at  term  is  greater    than    a    panhysterectomy  earlier.     Cesarean  section 


566  MYOMA  OF  THE  UTERUS 

at  the  time  of  labor  has  proved  to  be  too  dangerous,  except  in  the  hands 
of  men  of  experience  in  obstetrical  surgery,  to  justify  it  as  an  operation 
of  choice;  a  section  at  term  would  require  a  hysterectomy  later,  and 
the  combined  mortality  of  the  two  operations  would  certainly  be  greater 
than  that  of  a  hysterectomy  when  the  condition  is  discovered.  I 
believe  our  advice  to  the  patient  should  be  in  accord  with  these  facts. 
Accidents  in  the  Course  of  Development. — Independently  of  the  size  of 
the  uterus,  a  number  of  accidents  ma}^  require  treatment.  These  acci- 
dents are  usually  due  to  infection  of  myomas  either  after  abortion  or  after 
the  termination  of  pregnancy,  or  to  acute  disturbance  of  their  nutrition, 
or  to  both  combined.  Infection  may  occur  when  pregnancy  is  uninter- 
rupted, when  there  is  disturbance  in  nutrition  because  of  occlusion  of 
vessels.  Complete  or  partial  emptying  of  the  uterus  may  cause  sudden 
interference  in  nutrition  by  thrombosis.  Such  complications  are  of 
extreme  gravity.  Infection  of  the  interior  of  the  uterus  may  subside 
spontaneously,  or,  if  it  is  intramural,  the  inflammator}^  products  may 
subsequently  empty  into  the  uterus.  If  infection  occurs  in  the  interior 
of  tumors  the  same  thing  may  follow,  but  usually  the  extension  is  toward 
the  peritoneum,  so  that  abdominal  inflammation  results.  The  removal 
of  the  necrosed  or  infected  tumor,  with  drainage,  is  the  operation  of 
choice. 


CM  I  A  V'l  K  k     X  X  X  \   1  I  I 

CARCINOMA  Ol    nil.    I   IKRUS 

Frequency. — Nearl)-  one-foiirtli  of  :ill  tarcinonias  in  woiiitn  occur  in 
the  utrms,  and  nint-tenths  of  these  in  the  cervix.  It  is  estunated  that 
one  woman  ni  ten  over  forty  years  of  -dgt  suffers  from  this  disease, 
which  is  nearh  twice  as  frequent  as  carcinoma  of  the  breast,  trequent 
as  this  disease  realh'  is,  these  H<;ures  are  probably  exaggerated.  The 
statistics  are  usually  compiled  in  institutions  in  which  only  the  severer 
forms  of  women's  diseases  are  treated. 

Etiology.— The  frequency  of  carcinoma  of  the  uterus,  associated 
as  it  is  with  certain  physiological  and  pathological  conditions  of  this 
organ,  makes  it  an  interesting  stud\-  in  etiology,  not  only  with  respect 
to  this  organ  alone,  but  of  carcinoma  in  general.  The  conditions  referred 
to  are  connected  w-ith  the  function  and  accidents  of  reproduction  and 
\vith  the  inflammations  to  which  this  organ  is  subject. 

It  seems  warranted  to  accept  the  general  opinion  that  childbirth 
and  its  attending  accidents  increase  the  tendency  to  carcinomas;  in  tact, 
many  of  the  factors  believed  to  favor  the  development  of  epithelial 
tumors  are  coincidently  active  in  the  uterus.  Lacerations  produced 
by  every  childbirth  heal  with  the  formation  of  scar  tissue.  Frequently 
the  healing  process  is  delayed,  with  the  result  that  there  is  an  irregular 
development  of  the  squamous  cells  of  the  vaginal  portion  on  one  side 
and  the  columnar  cells  of  the  cervical  canal  on  the  other,  and  it  is  at 
this  point  that  the  malignant  prohferation  is  beheved  to  begin;  though 
it  is  questionable  if  this  relation  is  more  than  an  assumption  based  on 
cell  proliferations  associated  with  healed  erosions. 

The  factors  which  cause  delayed  or  irregular  healing  may  be  in  general 
divided  into  two  classes,  infection  and  circulatory  changes;  both  ot 
w^hich  bring  with  them  modifications  in  nutrition  of  the  field  in  question. 
Infection  ma\-  be  local,  occurring  at  the  time  of  labor,  or  may  be  due 
to  discharges  from  the  uterus.  An}-  abrasions  independent  of  labor, 
particularly  those  due  to  irritating  discharges,  produce  the  same  result. 
Infection  at  the  time  of  labor  is  probably  of  less  importance  than  other 
factors,  for  it  is  constantly  observed  in  operations  in  this  region  that 
infected  wounds  soon  heal  if  not  subjected  to  further  disturbance. 
Of  more  importance  in  the  light  of  our  present  knowledge  is  inflamma- 
tion  resulting  from  irritating  discharges  and   the  attendant  disturbed 


568  CARCINOMA  OF  THE  UTERUS 

circulation,  which  tends  further  to  increase  the  discharges.  Other 
causes  of  these  disturbances  of  circulation  are  displacements  of  the 
uterus,  periuterine  inflammations,  and  also  chronic  inflammations, 
specific  or  otherwise,  which  continually  produce  new  irritation.  These 
causes,  in  turn,  ma}^  depend  upon  faulty  social  or  physical  conditions. 

In  many  instances  carcinoma  begins  without  the  demonstrable  exist- 
ence of  any  of  these  conditions,  though  obviously  in  an}^  given  case 
they  cannot  be  excluded  with  certainty.  It  is  at  once  seen  that  the 
problem  becomes  as  broad  as  the  disease  of  the  uterus  is  general.  The 
belief  that  carcinoma  is  likely  to  occur  where  two  types  of  epithelium 
join  formed  a  prominent  factor  in  Cohnheim's  theory  of  neoplasms, 
and  it  is  in  the  cervix  that  this  part  of  his  theory  finds  its  chief 
substantiation;  yet  the  multiplicity  of  conditions  enumerated  above 
makes  it  questionable  whether  this  one  anatomical  factor  deserves  the 
prominence  it  has  received. 

Recent  studies  seem  rather  to  show  that  the  physical  and  chemical 
effects  of  the  pathological  secretions  of  the  uterus  are  more  potent 
factors.  The  opportunities  for  exact  study  offered  here  approach  those 
of  a  laboratory  experiment,  inasmuch  as  factors  known  to  be  associated 
with  the  development  of  carcinoma  are  often  clearly  present  and  seem 
to  deserve  more  careful  study,  because  of  their  theoretical  interest,  than 
they  have  received.  Unfortunately  for  such  study,  however,  carcinomas 
are  rarely  observed  in  their  early  stages  in  this  region. 

Classification. — Carcinomas  of  the  uterus  are  divided  into  those  of 
the  cervix  and  those  of  the  body  of  the  uterus.  The  former  are  again 
divided  into  those  of  the  vaginal  portion  and  those  of  the  neck.  Since 
the  body  of  the  uterus  and  the  cervical  canal  are  lined  with  columnar 
epithelium,  carcinomas  beginning  in  these  regions  are  of  the  glandular 
variety,  while  those  beginning  in  the  vaginal  portion  of  the  cervix  are 
squamous-celled.  The  usual  site  of  origin  is  perhaps  the  junction  of 
the  squamous  and  columnar  epithelium,  which  is  usually  at  the  narrowest 
point  of  the  external  os. 

Carcinoma  of  the  Cervix. — Pathogenesis. — It  is  customary  to  divide 
carcinoma  of  the  cervix  into  the  polypoid  and  the  crateriform  types. 
These  may  with  equal  frequency  exist  as  mixed  forms  in  which  the 
newly  formed  tissue  may  extend  beyond  the  surface  in  one  portion, 
while  in  another  area  an  ulcer  may  result.  Or  one  or  the  other  of  these 
lesions  may  predominate  in  different  stages  of  the  disease.  Culleni 
does  better  by  dividing  the  disease  into  three  stages:  (i)  Before  there 
is  loss  of  tissue;  (2)  where  there  is  moderate  loss  of  tissue;  and  (3)  where 
there  is  extensive  or  complete  disintegration  of  the  cervix.     The  defect 

^  Cancer  of  the  Uterus,  Appleton,  New  York,  1900. 


C.IRCISOM.I  (Jl    Till:   Cl.Kl  IX 


rm 


in  this  (.hissihiatioii,  ;is  shown  h\  ihi-  stuclifs  of  S;iin|)son,  is  th;it  rhi- 
extent  ot  loss  ot  tissui-  (Iocs  not  ;il\\;i\s  cot  it-spoiul  to  thr  ilinical  sta^t- 
of  the-  chsi;isc.  1  have,  rhtrifoic,  tor  convtniciuc  in  discussion,  and 
in  iiulicarin^  ritatnunr,  divided  (.aicinonias  of  the-  cervix,  whether 
siiuamons  or  coUiinnar,  into  three  classes:  (i)  Where  the  disease  is 
conHned  to  the  cervix;  2)  where  the  |Hriiitei  iiu-  tissue  is  invaded,  hur 
the  unriis  is  tVicl\    mo\:ihl<-;   13)  wlure  tlu'  pc  riutirine  tissue  is  invaded 


KiG.  402 


Fk;.  403 


Beginning  carcinoma  of  the  cervix. 
(Drawn  from  a  photograph  loaned  b\- 
Dr.  John  A.  Sampson.) 


Carcinoma  of  the  cervix.      Same  as 
Fig.    402,   but   more   advanced. 


and  the  uterus  is  fixed,  or  where  one  of  the  neighboring  organs,  ureter, 
bladder,  rectum,  or  some  more  distant  organ,  is  involved.  It  must 
be  admitted  that  a  sharp  division  cannot  be  made  anatomicari\-  or 
chnically  in  all  cases,  but  with  this  scheme  in  mind  the  surgeon  will 
often  be  able  to  come  to  a  practical  conclusion  as  to  the  advisability 
of  operative  treatment. 

PiRST  Stage. — In  the  beginning  there  is  an  abnormal  extension  of 
epithelium  into  the  connective  tissue  beneath,  forming  nests  which  maA- 
or  maA-  not  project  above  the  surface  (Figs.  402,  403,  and  404).     About 


570 


CARCINOMA  OF  THE  UTERUS 


this  area  are  the  usual  connective-tissue  changes  incident  to  carcinoma. 
The  mass  is  ill  defined;  it  may  be  detected  by  the  palpating  finger  when 
the  nodules  are  but  a  few  millimeters  in  diameter,  or  the  tumor  may  be 
marked  by  a  reddened  area  from  which  small  teat-hke  prominences 
a  few  millimeters  in  height  and  diameter  extend  above  the  surface. 
These  form  at  one  quadrant  of  the  cervix  and  not  at  the  beginning 
about  the  entire  circumference.  These  invasions  or  elevations  increase 
in  number  until  a  tumor  projects  into  the  vagina  or  until  the  entire  cervix 
is  invaded.  The  amount  of  connective  tissue  presents  every  variation 
and  in  common  with  all  carcinomas  may  originate  from  the  preexistent 
cervical  tissue,  or  it  may  be  newly  formed.  Masses  large  as  an  egg  are 
not  uncommon,  and  sometimes  the  entire  vagina  is  filled  by  a  cauliflower- 

FiG.  404 


Carcinoma  of  the  cervix. 


like  growth.  At  the  same  time  the  surface  may  break  down  and  form 
an  ulcer.  In  extensive  cases  a  large  crateriform  opening  may  take  the 
place  of  the  cauliflower-like  tumor.  Such  extensive  involvement  of 
the  cervix  is  possible  while  the  growth  is  still  confined  to  the  cervix; 
the  extent  of  the  tumor  is,  in  fact,  no  index  to  the  stage  of  the  disease. 
Second  Stage. — The  last  statement,  unfortunately,  has  a  greater 
negative  than  positive  value,  for  with  a  very  small  cervical  lesion 
apparent  the  entire  thickness  of  the  cervix  may  be  involved  (Fig.  405), 
and  the  disease  may  already  have  progressed  into  the  periuterine  tissue. 
Indeed,  in  the  columnar  type  the  invasion  of  the  periuterine  tissue  may 
occur  even  before  the  growth  is  apparent  in  the  cervix.  Extension  is 
by  way  of  the  lymphatics  and  the  connective-tissue  spaces.  Columns 
of  cells  sometimes  extend  laterally  from  the  cervix,  and  form  secondary 


CJRCIAOM.l  OF   Tin:  CERI  l\ 


571 


iiocliilfs  111  tlu-  imiiuilKiti-  \Kinir\  ot  tin-  prim;ii\  tiimoi;  tluy  may  he- 
solitary  or  may  In-  commiioiis  with  ii.  I  he  extension  ma\  be  upward 
toward  the  tiindus  of  the  uterus,  but  usually  this  occurs  to  a  slif^ht  decree 
only,  the  external  os  beinj^  rarely  exceeded;  extension  downward,  however, 
into  the  loose  perivaginal  tissue  is  sometimes  earl\'  and  extensive. 

Fig.  405 


Carcinoma  of  the  cervix.     The  broad  ligament  has  been  invaded  at  the  right  of 

the  figure. 


Third  Stage. — By  extension  to  the  surrounding  tissue  (Figs.  406 
and  407)  the  growth  may  involve  the  ureters,  the  rectum,  vagina,  or 
large  bloodvessels,  or  give  rise  to  metastases  in  distant  organs.  The 
invasion  of  the  surrounding  organs  is  bv  gradual  extension,  and  this 
stage  is  simplv  a  continuation  of  the  previous  stages.  The  entire  pelvis 
may  become  filled  with  a  carcinomatous  mass  before  the  original  lesion 
becomes  manifest.  \\  hen  the  ureters  are  involved,  it  is  usually  by 
compression  rather  than  by  invasion,  they  being  protected  by  a  fibrous 
sheath  (Sampson).  The  rectum  is  also  more  often  affected  b\'  compres- 
sion alone,  though  invasion  may  occur  w^ith  projection  into  the  gut  of 
masses  which  give  rise  to  the  symptoms  of  rectal  carcinoma.  In  fact, 
the  first  evidence  of  uterine  carcinoma  may  come  from  such  rectal 
symptoms.    The  bladder  more  often  than  the  rectum  is  affected  by  direct 


572 


CARCINOMA  OF  THE  UTERUS 


extension,  and  the  reddish  granular  surface  of  the  advancing  carcinoma, 
as  observed  by  the  cystoscope,  may  furnish  the  earliest  evidence  that 
the  disease  is  inoperable.  The  involvement  of  the  perivaginal  tissue  is 
rarely  extensive,  but  may  be  so  great  as  to  narrow  the  vagina  so  that 
only  one  finger  can  be  introduced.  The  vaginal  mucous  membrane 
may  be  attacked  and  ulcerated,  or  may  be  unaffected. 


Fig.  406 


Fig.  407 


Carcinoma  of  the  cervix  involving  the 
entire  cervix,  and  invading  the  broad 
ligaments  and  vaginal  vault. 


Carcinoma  of  the  cervix.      Extensive  inva- 
sion of  the  perimetrium 


Metastasis.^ — The  question  of  metastasis  has  received  extensive  study, 
but  our  knowledge  regarding  it  is  as  yet  unsatisfactory.  In  general,  it  may 
be  said  that  metastasis  is  relatively  late.  In  less  than  one-half  of  women 
dead  from  carcinoma  is  there  lymphatic  metastasis;  and  when  it  does 
occur,  it  IS  most  likely  to  be  in  the  iliosacral,  the  sacral,  or  the  retro- 
peritoneal glands.    The  only  way  to  determine  this  question  is  to  remove 

Sampson,  Jour.  Amer.  Med.  Assoc,  1904,  xliii,  1271;  Clark,  Surg.,  Gyn.,  and  Obst., 
1906,  ii,  146. 


s)-\i/'/()Ms  /\  (:,iR(:i\()M  I  oi    riii:  iti.kis  :u.\ 

(1r-  l;,I.iiu1.s  .It  iipci  .It  Kin  .iiul  m.ikr  tauliil  stii;il  srctioiis,  ;is  was  doiu- 
In    Kits." 

OfKimKl'  li.is  m.ulc  (\t(iisi\c  siiulus  ()l  metastases  in  the  iciitiiil 
iHTVous  s\  stiiii.  I  Ir  i;ills  arriiitioii  to  the  fact  that  hiaiii  nurastases 
nia\'  I'll-  pri'Stiit  wink  tlu-  piimaiy  tiiiiioi  is  snll  opiiahlc.  I  he  same 
aurhoi  has  sriuhid  xisctial  nurastascs.  Mr  hiuls  h\(i  nurasrasc-s  in 
from  5  to  S :;  pef  ci  iit .  ot  casts.  I  he  \  a  iih  of  tlic  ciiaphia^;m,  tlic  onu-iitiim 
and  the  intestinal  walls  are  likewise  fax'or.ihie  seats  for  secondary 
deposits. 

Symptoms.'  I  he-  first  s\  ni|Honi  ot  nian\  supcituial  iicoi^lasnis  is  the 
discox'ery  of  a  tumor.  Neoplasms  of  the  internal  organs  are  often  first 
e\ident  h\  the  disturbed  function  of  tiie  organ  imolxed.  I  lie  uterus, 
in  a  sense,  stands  muiwa\  between  external  and  internal  organs;  it 
IS  subject  to  external  examinations,  but  usuallv  some  disturbance  of 
function  Hrst  directs  attention  to  the  presence  ot  a  tumor.  Ihis  dis- 
turbance of  function  is  unquestionably  hrst  evident  as  an  abnormal 
discharge,  either  serous  or  bloody.  Pam,  because  of  the  insensitive 
region  diseased,  is  always  late.  The  occurrence  of  ichorous  discharge 
is  a  very  Lite  symptom,  and  though  made  much  of  by  older  writers, 
IS  not  worth\'  of  a  place  in  the  symptomatology  of  the  disease.  1  hese 
\arious  symptoms  ma)'  be  taken  up  in  detail. 

The  earliest  symptoms  of  carcinoma  of  the  uterus  are  indeHnite 
in  character.  1  here  is  nothing  to  distinguish  the  leucorrheal  discharge, 
the  pelvic  discomfort,  the  backache,  and  the  reflex  disturbances  which 
mark  the  earliest  beginnings  of  carcinoma  from  benign  inflammatory 
and  circulatory  disturbances.  A  diagnosis  at  this  time  can  be  made 
only  when  these  slighter  disturbances  of  the  pelvic  organs  are  made 
the  object  of  close  study.  It  cannot  be  too  strongly  urged  that  any 
pelvic  disturbance,  particularly  when  it  appears  in  women  near  the 
menopause  after  some  }'ears  of  sterility,  is  a  sign  of  disease  the  character 
of  which  should  be  definiteh'  determined.  In  fact,  a  discharge  which 
appears  after  the  menopause  must  be  regarded  as  presumptive  evidence 
of  malignanc\'  until  disproved  h\  examination. 

Hemorrh.age. — Hemorrhage  is  too  often  regarded  by  the  profession 
as  the  earliest  symptom  of  carcinoma,  and  unless  some  suspicious  hemor- 
rhage has  taken  place,  the  possibility  of  the  existence  of  carcinoma  is 
often  not  entertained.  Yet  from  the  ver}'  nature  of  the  carcinomatous 
process  hemorrhage  cannot  be  a  very  early  symptom,  because  it  must 
be  preceded  by  some  loss  of  substance,      lliis  applies,  ot  course,  to  those 

'  Jour.  AiiKT.  .Med.  Assoc,  1906,  \1\  ii,  1869. 

-  Ztschr.  f.  Geburtsh.  u.  Civniik.,  1908,  ixiii.  i. 

^  Arch.  f.  Gyniik.,  1909,  Ixxxvii,  144. 

^  Clark,  Jour.  Amer.  Med.  Assoc,  1906,  xlvii,  1865. 


574  CARCINOMA  OF  THE  UTERUS 

parts  of  the  uterus  not  concerned  in  the  menstrual  flow.  Moreover, 
early  hemorrhage  is  unfortunately  likely  to  be  ignored  when  it  occurs 
in  women  who  are  nearing  the  menopause,  in  whom  deviation  from 
the  normal  course  of  the  menstrual  flow  is  commonly  ascribed  to  the 
approaching  change.  It  is  only  when  it  becomes  alarming  that  the  warn- 
ing is  heeded  and  the  cause  sought.  Hemorrhage  in  its  incipiency  is 
not  likely  to  be  properly  interpreted  unless  it  occurs  after  a  period  of 
menopausal  amenorrhea. 

In  carcinoma  of  the  uterus,  unless  other  disease  leads  the  patient 
to  a  gynecological  examination,  the  early  symptoms  go  unheeded.  A 
woman  who  has  ceased  to  menstruate  and  again  bleeds  must  be  con- 
sidered to  have  carcinoma  until  its  presence  is  disproved.  The  character 
of  the  hemorrhage  is  variable;  usually  there  is  a  recurrence  between 
the  menstrual  periods;  a  prolongation  of  the  flow  is  less  significant. 
When  it  occurs  after  the  menopause  it  is  usually  slight  and  dribbling, 
and  returns  at  irregular  intervals.  The  blood  is  preceded  or  followed 
by  serous  discharge.  Sometimes  there  is  an  initial  severe  hemorrhage 
which  threatens  the  life  of  the  patient  b}^  exsanguination. 

Pain. — Pain  associated  with  carcinoma  may  be  due  to  circulatory 
disturbance  or  to  invasion  of  the  nerves.  In  the  former  there  may  be 
only  the  sense  of  discomfort  or  localized  dull  pain  common  to  many 
pelvic  disorders.  The  latter  type  is  present  only  after  the  growth  has 
invaded  the  tissue  lateral  to  the  cervix.  It  is  lancinating  in  character 
and  radiates  to  the  groin,  the  suprapubic  region,  the  hips  or  thighs, 
or  to  the  epigastrium.  It  is  intermittent  at  first,  and  only  when  the 
disease  is  far  advanced  does  it  become  continuous.  In  some  instances 
pain  may  not  occur  until  the  tumor  becomes  large  enough  to  compress 
other  organs. 

Fetor. — Ichorous  discharge  from  sloughing  masses  is,  like  cachexia, 
a  late  manifestation,  and  occurs  only  after  malignant  tissue  becomes 
necrotic  and  the  seat  of  putrefaction.  The  older  gynecologists  prided 
themselves  on  their  ability  to  diagnosticate  carcinoma  of  the  uterus 
by  the  sense  of  smell.  The  odor  is  striking,  and  is  often  detected  at 
once  when  the  patient  is  approached;  but  it  is  distinctive  of  nothing 
except  necrotic  flesh. 

Indirect  Symptoms. — Indirect  symptoms  occur  in  carcinoma  which 
are  in  no  wise  required  for  diagnosis,  but  appear  as  comphcations  in 
hopeless  cases,  although  unfortunately  they  are  too  often  the  first 
evidence  of  the  disease,  and  much  oftener  still  are  the  symptoms  which 
bring  the  patient  to  seek  advice.  They  are  due  to  invasion  of  neighbor- 
ing organs.  A  cystitis  may  occur  from  invasion  of  the  bladder  or  from 
ulceration  into  it,  and  the  rectum  may  be  similarly  invaded;  vesico- 
vaginal  and   vesicorectal  fistulas   may   thus   be  formed.     Contractions 


J)/.J(;.\(JS/S  OF  C.IRCISOM.t  OF   rilF  I  TERL'S  .')7o 

ot  tlu-  t:ut  Mi;iy  cause  obsniKrion.  I  In-  uitrii  may  ho  artcctt-d  by  the 
growrh,  though  less  often  hy  iinasioii  rhaii  h\'  compression,  and  a 
ureteritis  may  result.  Hydrcjnephrosis  nia\  he  the  Hrst  sign  that  leads 
to  the  discovery  of  a  uterine  carcinoma. 

Cachexia  and  loss  of  strength  are  usuall\'  coincident  with  interference 
with  the  tunctioii  ot  organs  and  witli  the  loss  ot  hlood.  I  he  ad\anced 
stages  of  the  disease  are  characterized  hy  more  c^r  less  constant  pain, 
caused  hy  irritation  of  the  pelvic  nerves  b\'  the  other  complications  that 
ma\'  arise.  Chronic  intestinal  obstruction  with  attendant  intoxication 
often  aids  materiall\'  in  exhausting  the  patient.  Uremia  from  obstruc- 
tion of  the  ureters  is  not  uncommon.  Metastases  rarely  produce 
important  clinical  symptoms  and  rarely  contribute  to  the  cause  of 
death.  Piuuinonia,  easil)'  contracted  in  her  weakened  state,  often 
mercitullx"   relieves  the  patient. 

Diagnosis. —  Because  of  the  insidious  onset  of  carcinoma  ol  the  uterus, 
and  because  a  ready  inspection  of  the  diseased  area  is  complicated  b\' 
difficulties  other  than  the  inconveniences  of  examination,  there  is  no 
other  region  of  the  bod\'  in  which  the  earl\'  recognition  of  the  disease 
depends  so  much  upon  the  clinical  acumen  ot  the  surgeon.  1  he  most 
important  point  in  the  diagnosis,  let  it  be  repeated,  is  to  suspect  carci- 
noma. If  this  possibilit)-  presents  itself  to  the  surgeon,  and  leads  him 
to  make  an  examination,  it  is  onh'  in  the  rarest  cases  that  he  has  any 
difficulty  in  either  confirming  or  disproving  his  suspicions. 

Unfortunately,  the  person  to  whom  suspicious  symptoms  first  present 
themselves  is,  of  course,  the  patient  herself,  and  she  is  too  often  unable  to 
recognize  them.  The  widespread  education  of  women  who  are  approach- 
ing the  carcinomatous  age  to  recognize  the  first  signs  of  the  disease 
is  greatly  to  be  desired.  The  average  intelligence  of  women,  unfortu- 
nately, is  not  such  that  a  general  effort  at  education  can  be  expected 
to  have  a  very  great  effect,  but  it  would  seem  that  a  dissemination  of 
knowledge  is  worth  the  effort. 

The  significance  not  only  of  recurrent  hemorrhage  after  the  meno- 
pause, but  also  of  deviation  from  the  normal  flow  and  of  the  milder 
pelvic  disorders  before  the  menopause,  should  be  understood  by  every 
woman.  They  should  be  taught  that  such  disturbances  are  not  a  part 
of  the  normal  menopause.  Those  later  menstrual  perversions  which 
announce  the  breaking  down  of  carcinoma  are  far  more  difficult  to 
present  to  the  lay  mind,  and  the  profession  had  better  content  itself 
with  impressing  the  simple  fact  that  any  unusual  hemorrhage  should 
be  the  signal  for  an  examination  by  her  doctor.  With  this  our  efforts 
at  popular  education  should  cease.  To  present  fetid  discharge  and 
lancinating  pain  to  the  lay  mind  as  symptoms  of  carcinoma  of  the  uterus 
is  reprehensible.     Time    and    again    I   have   been  consulted   by  women 


576  CARCINOMA  OF  THE  UTERUS 

who  had  waited  when  afflicted  with  unusual  or  postmenopausal  hemor- 
rhage for  the  appearance  of  the  ill-smeUing  discharges  or  lancinating 
pains  which  they  had  learned  to  regard  as  the  leading  signs  of  beginning 
carcinoma.  The  lait}^  need,  as  a  matter  of  fact,  to  know  nothing  of 
pathognomonic  signs;  to  teach  them  suspicions  is  quite  enough. 

When  the  victim  of  carcinoma  of  the  uterus  presents  herself  to  the 
physician,  the  responsibility  for  the  proper  interpretation  rests  with 
him.  His  means  of  meeting  the  responsibility  is  a  careful  examination, 
including  palpation,  inspection,  and,  inversely  to  his  experience,  a  micro- 
scopic examination.  The  palpating  finger  detects  at  once  the  dense 
nodular  feel  imitated  by  nothing  else.  The  lesion  when  early  is  confined 
to  one  quadrant  of  the  os,  later  the  entire  circumference  may  be  in- 
volved. A  nodule,  a  cauliflower  mass,  or  a  crater  may  be  present,  but 
there  is  always  the  same  dense  feel  and,  on  inspection,  the  same 
appearance  of  a  granular  surface. 

The  frequency  with  which  microscopic  examination  should  be 
made  is  difficult  to  determine.  The  experienced  surgeon  very  rarel}^ 
needs  this  assistance  in  order  to  make  the  diagnosis.  On  the  other 
hand,  the  removal  of  a  section  tends  to  invite  metastasis,  and  hastens 
the  growth  of  the  disease  should  it  be  carcinoma.  There  can  be  but 
one  logical  procedure.  The  welfare  of  the  patient  is  served  better  by 
subjecting  her  to  the  trained  eye  and  fingers  of  a  competent  surgeon 
than  by  sending  a  small  section  of  the  diseased  area  to  the  microscopist. 
If  it  is  deemed  best,  however,  to  make  a  diagnostic  excision,  a  triangle 
should  be  cut  out  in  such  manner  that  the  pathologist  may  determine 
the  direction  in  which  to  make  the  sections.  It  is  much  less  objection- 
able to  make  a  diagnostic  section  at  the  time  of  operation  than  it  is  to 
transport  the  excised  tissue  to  a  pathologist  so  that  a  radical  operation, 
if  necessar}^,  can  follow  only  some  days  later. 

Unfortunately,  the  majority  of  uterine  carcinomas  when  they  are 
first  examined  are  so  far  advanced  that  the  nature  of  the  affection 
cannot  be  doubted. 

The  majorit\  of  the  sections  sent  for  diagnosis,  usually  from  doubtful 
cases,  are  from  simple  erosions.  In  these  a  diagnostic  section  is  not 
objectionable,  and  a  study  of  a  number  of  such  sections  soon  enables, 
the  operator  to  anticipate  the  findings  of  the  microscope.  It  is  desirable 
that  the  surgeon  himself  make  the  microscopic  examination,  for  if  he 
relies  upon  the  pathologist,  his  own  mental  vision  is  not  expanded  and 
the  same  error  is  repeated.  However,  there  is  an  abundance  of  material 
for  such  study,  obtained  in  cervical  amputations  and  in  the  repair  of 
lacerations,  without  subjecting  patients  to  the  inconvenience  of  a  diag- 
nostic section. 

The  study  of  such  tissue  cannot  be  too  strongly  urged  upon  those 


n/./(:.\(js/s  or  c.ikcisom  i  oi   rm:  i  i i:ki  s 


at  I 


whii  (xpict  to  nssimu  ilic  r(s|>()nsil)ilii  \  ol  (liiinnostii-atin^  i;iil\  t;iiii- 
ii()in;i;  toi ,  olix  i()iisl\  .  .1  know  K(l<;f  ol'  i  he  »;irl\  ih;inm-s,  w  Inch  ;ii  c,  of 
course,  niicioscoi^ic,  must  he-  posscssid  l)\  tin  observer.  Hanseniann 
lon«j;  a^o  expressed  skeprifisiii  as  to  the  \aliic  of  arrenipr  ro  detect  the 
finer  changes  111  thi-  cells  ol  carl\  laixinoma  ohtaiiud  l)\  ciirettaf^e. 
rhou}z;h  volmius  lia\c  siiui'  In-eii  written  npon  the  snhiect,  it  is  t)i\' 
opinion  that  his  \  iew  is  correct.  1  have  made  many  hundieds  of  sections 
ot  snch  tissue,  and  have  never  yet  seen  a  dia^iiiosis  made  bv  this  means 
that  couKl    not  haw  heeii  made  on  thf  climcal  exideiice  alone. 

Differential  Diagnosis.  in  the  tdllowin^;  paragraphs  an  arf(iii|)t  will 
he  mack'  to  enumerate  those  conditions  which  are  most  likeh  to  be 
mistaken  tor  hc\t!;innin<;  carcinoma  of  the  cervix,  and  to  indicate  briefl\- 
the  points  which  must  be  kept  in  mind  in  :im\in<^  at  a  differentiation. 
1  he  discussion  will  follow  the  approximate  order  of  fre(|uenc\-  of  the 
condition. 


"ui.  408 


Fig.  409 


Eversion  of  the  cervix,  showing  a  sharp 
line  of  demarcation  between  the  eroded 
area  and  the  normal  cervix  beyond. 
Mucous  plug  in  the  os. 


Eversion  of  the  cervix,  showing  a 
sharply  defined  line  between  the  lesion 
and  the  normal   portion  of  the  cervix. 


Eversion  of  the  Cervical  Mucosa  (Erosions  of  the  Cervix). — 
No  better  material  exists  for  the  study  of  early  epithelial  changes 
than  the  erosion  and  other  lesions  of  the  cervix  which  resemble  carci- 
noma. Erosion  results  from  lacerations  of  the  cervix  due  to  labor  or  to 
instrumental  dilatation  of  the  os,  or  from  inflammatory-  lesions.  As 
a  result  ot  the  chronic  irritation,  the  columnar  mucosa  lining  the  cervical 
canal  hypertrophies,  so  that  it  projects  into  or  without  the  external 
OS.  In  such  instances  the  cervical  mucosa  may  cover  the  vaginal  por- 
tion of  the  cervix  over  an  area  of  a  few  millimeters  to  a  centimeter  or 
more  in  place  of  the  S(]uamous  epithelium  normal  to  the  part.  Since 
erosion  implies  a  loss  of  the  covering  epithelium,  the  term  is  inapplicable 


578  CARCINOMA  OF  THE  UTERUS 

to  the  above-described  condition,  which  is  really  a  displacement  of 
the  light  pink  squamous  epithelium  by  the  deep-red  columnar  epithe- 
lium of  the  cervical  canal.  However  the  displacement  may  be  brought 
about,  the  appearance  is  the  same.  There  is  observed  about  the  external 
OS  a  red  border  of  greater  or  less  extent  (Fig.  408),  soft  to  the  touch 
and  not  bleeding  when  irritated  by  the  finger  or  instrument.  The 
border  between  the  red  everted  mucosa  and  the  squamous  epithelium 
is  sharp  (Fig.  409),  a  definite  line  of  demarcation  separating  the  two, 
so  that  within  a  milhmeter  or  two  it  is  possible  to  say  where  the  one 
ends  and  the  other  begins.  Usually  the  eversion  extends  nearly  or 
quite  around  the  entire  os,  because  the  mechanical  or  inflammatory 
factors  active  in  one  area  are  active  over  the  entire  circumference  but  in 
some  instances  a  polypoid  eversion  of  the  mucosa  at  one  quadrant  (Fig. 
409)  occurs.  Its  softness  and  the  lack  of  disposition  to  bleed  shows  its 
benign  nature.  The  test  handed  down  by  the  older  authors,  to  deter- 
mine if  an  eversion  is  present,  consisted  in  grasping  each  side  of  the 
cervix  with  volsella  and  drawing  down.  If  the  reddened  area  disap- 
peared it  was  regarded  as  an  eversion.  This  sign  holds  good  in  the 
severe  cases  of  bilateral  lacerations  only.  An  attempt  to  apply  it  where 
the  laceration  is  less  in  extent  and  the  inflammatory  induration  greater 
will  fail,  and  if  relied  upon  will  lead  the  examiner  to  erroneous  con- 
clusions. 

Contrasted  with  these  findmgs  in  eversion,  we  have  in  carcinoma 
usually  but  one  quadrant  involved  or  more  extensively  involved,  instead 
of  the  extension  about  the  entire  os.  It  must  be  emphasized  that  this 
applies  to  the  very  early  cases  only,  for  frequentl}^  when  the  patient 
is  examined  the  carcinoma  has  extended  more  or  less  about  the  entire 
os;  even  then,  one  portion  of  the  cervix  is  more  involved  than  the  rest. 
The  border  between  the  carcinoma  and  the  epithelium  of  the  cervix  is 
not  sharp  (Fig.  404);  there  will  be  gradual  shading  off"  from  the  deep 
red  of  the  neoplasm  to  the  light  pink  of  the  squamous  cervical  epithe- 
lium, and  here  and  there  a  tongue  of  redder  cervical  epithelium.  It  is 
by  the  touch  that  the  greatest  diff^erence  can  be  detected;  the  cervical 
mucosa  of  the  erosion  is  soft  and  velvety,  while  in  carcinoma  it  is  dense 
Hke  elastic  cartilage,  and  the  surface  is  nodular.  To  the  trained  finger 
this  IS  pathognomonic;  the  microscopic  examination  can  add  but  little 
to  its  certainty.  On  gentle  manipulation,  this  surface  bleeds  and  with 
moderate  violence  the  nodular  surface  can  be  scraped  off". 

Cystic  Degeneration  of  the  Cervical  Glands. — The  positive  evi- 
dence of  the  dense  feel  in  cancer  is  sometimes  for  the  beginner  confused 
by  the  occurrence  in  the  cervix  of  small  cysts  tensely  filled  with  mucus, 
which  results  from  the  occlusion  of  the  ducts  of  the  cervical  glands. 
They  appear  as  round,  hard  bodies  buried  deeply  in  the  cervical  tissue. 


D/.n:.\(jsis  Of  i:,iKi:i\()M.i  or  nil.  i  tkris  579 

and  i.;iii  In-  iikuIc  out  l)\  p;ilp;i t loii.  COinljiiud  with  tluni  at  tmics 
!s  tin-  iNiision  t)t  ilu  miuosa  alicail\  imntioiud.  It  is  usiiallv  possible 
to  niaki-  out  tin-  soli,  \i  Kcty  feel  of  tin-  iniiiosa  covering;  these  cysts, 
and  tluy  do  nor  hKt-d  on  palpation.  ( )n  iiisprction,  the  pearl\'  blue 
cystic  contents  may  shiinincr  thiouiili  thi  mucosa.  In  case  of  douht 
tluy  ma\  In-  puiutun-d  hy  a  small  kmh-,  wlun  the  escape  ot  rluir 
mucinous  contents  cleats  up  all  douht.  A  vved^e-shaped  piece  can  he 
exsected  and  the  condition  examim-d  microscopicalh',  thoujih  this  is 
not  necessary. 

C'k  AiKiciAi  Indi  R.\  rioN.  Small  cicatricial  areas  ma\  he  loinied 
dunnti;  the  lualmt!;  jnocess  of  a  laceration,  which  on  ]ial|")ari()n  may  he 
contused  with  carcinoma  nodules.  Such  scars  are  hard,  usually  stTiooth, 
sharply  confined,  and  do  not  bleed.  On  inspection,  their  pale,  whitish 
color  and  contmuit)'  with  a  scar  contrasts  them  sufHcientlv  from  carci- 
nomatous nodules. 

EvERTKD  Polypoid  Tumors.— A  variety  of  polypoid  tumors  within 
and  about  the  external  os  (Fig.  407)  ma\'  be  confused  with  a  fungating 
carcinoma,  though  it  must  be  stated  that  they  cause  more  confusion 
in  the  books  than  the}'  do  when  seen  clinically.  Sloughing  fibroids  are 
seen  most  frequently.  The  surface  may  be  necrotic,  giving  a  malodorous 
discharge,  and  hemorrhage  ma}'  have  taken  place.  On  examination, 
their  constricted  w'ell-defined  base  characterizes  them.  There  is  an 
additional  safeguard  to  error  in  the  absence  of  the  hardness  so  t\'pical 
of  carcinoma.  Pol\pi  of  the  mucous  membrane,  which  are  so  often 
accompanied  b}^  protracted  hemorrhage,  are  easily  differentiated  by 
noting  their  soft  feel  and  constricted  base.  Their  structure  is  described 
on  another  page. 

Ulceration  of  the  Cervix. — Simple  ulcerations  of  the  surface  may 
occur  either  from  traumatism  or  from  infection.  The  loss  of  epithelium 
can  be  noticed  b}'  observing  the  border  of  the  existing  epithelium.  1  he 
base  of  the  ulcer  may  be  fineh'  granular  or  covered  b\'  a  membrane 
specific  to  the  type  of  infection.  It  ma}'  bleed  readih',  but  to  the 
touch  It  IS  soft.  In  chronic  ulcerative  processes,  microscopic  pictures 
may  be  present  showing  irregular  gland  proliferation,  which  ma}'  lead  to 
confusion. 

Specific  ulcerative  processes  are  noted  in  rare  instances.  Tuberculosis 
appears  as  an  ulcer  w'ith  overhanging  border  and  granular  or  membrane- 
covered  base.  S}'philis  as  a  primar}'  lesion  is  rare;  the  lesion  is  regularl}' 
indurated,  and  does  not  differ  from  the  same  lesion  occurring  on  the 
glans  penis.  Usuall}',  there  are  other  evidences  of  s}'philis  present, 
and  the  primai}'  ulcer  is  found  onl}'  after  a  deliberate  search  instituted 
because  of  the  presence  of  other  lesions.  Poh'poid  s}'philitic  lesions 
about  the  cer\"ix  lack   the  induration  of  carcinoma.     Gummatous   pro- 


580 


CARCINOMA  OF  THE   UTERUS 


cesses  are  said  to  form  crateriform  ulcers  with  serpiginous  outline.  If 
thought  necessary,  a  microscopic  examination  or  a  serological  or  thera- 
peutic test  might  be  undertaken. 

Microscopic  Diagnosis. — It  was  the  habit  a  few  years  ago  to  discuss  at 
great  length  the  finer  changes  in  the  cells  in  beginning  carcinoma.  It  was 
sought  to  discover  the  very  early  changes,  so  that  the  disease  could  be 
detected  while  still  confined  to  a  few  glands.  Much  was  said  about  the 
differentiation  between  carcinoma  and  healed  erosions  (Fig.  410).      The 


Fig.  410 


Healed  erosion,  showing  squamous  epitlielium  growing  into  a  gland. 

observation  that  the  errors  were  all  made  on  the  side  of  mistaking 
healed  erosions  for  carcinoma,  and  the  needless  sacrifice  of  uteri  guilty 
of  no  greater  offence  than  harboring  an  eversion,  led  me  years  ago  to 
caution  my  assistants  that  when  in  doubt  the  lesion  probably  was  not 
malignant.  Carcinoma  of  the  cervix  does  not  differ  in  its  pathogenesis 
from  carcinoma  elsewhere,  and  it  is  needless  to  lay  down  a  large  number 
of  rules  for  the  detection  of  the  disease  in  this  region.  Those  who  have 
a  knowledge  of  the  structure  and  development  of  carcinoma  elsewhere 
will  find  no  difficulty  in  applying  the  same  rules  here.     Those  who  have 


(:,iRi:i\()\i.i  oi  rill:  iuidy  or  nil.  i  rrnrs 


:.M 


not    this     traiiiini:     \sill    do    will    to     hioiidiii     tlitii     i\|h-!  ii-nct-    hetorc 
arrrmptiiiL!,  i;iil\    cIkij;ii<)sis  ot  (.aninoina  ot   tin-  iittiiis. 

Carcinoma  of  the  Body  of  the  Uterus.  Caiciiioma  ot  tin-  hndv  ^A' 
tin-  iiriius  is  Init  oiu-ttiuh  as  tiiiiuciit  as  tliat  (jt  tin-  tii\i\,  ami  is  of 
tin-  coluiiiiiai-tilltil  r\  pe  alone.     It  occurs,  in  Kencial,  later  in  lift-  rlian 

1    the    pi()<iiiosis    IS   ^ciuiaiU     ir^ai dc-d    as    miu-li 


ciiNical    caiciiioma,    and    t 
mote-   taNoiaMf. 


Fig.  411 


1 


Q^^&& 


o*^ 


^■fS?J1? 


&6<' 


.« 

i 

Q. 


C?i 


#■  ^  e  *^  ov  ^1  ^  f^  =  o<:& 


r#/^^.t^     vj:^^ 


Hyperplastic  endometritis,  showing  interglandular  hyperplasia. 


Pathology. — The  attempt  to  divide  the  mahgnant  epithelial  tumors 
of  the  fundus  into  malignant  adenomas  and  adenocarcinomas  has 
caused  confusion,  and  there  is  wisely  a  reaction  against  the  use  of  the 
former  term.  Like  other  malignant  glandular  growths,  they  begm  by 
a  proliferation  of  the  glands,  so  that  they  extend  beyond  the  normal 
bounds.  The  dividing  line  between  the  benign  and  the  malignant 
hypertrophies  is  particularly  difficult  to  place,  because  ot  the  absence 
of  a  definite  basement  membrane.  The  occurrence  of  glands  deep 
in  the  siibmucosa,  extending  even  between  the  muscle  bundles,  is  not 
considered  alarming  because  of  the  frequency  of  congenital  glandular 
rests  in  this  region. 

Glandular  hypertrophy  (Figs.  411  and  412)  may  be  extensive,  but 
the  cells  remain  one  la^er  deep  and  the  interstitial  cells  are  much  in- 


582 


CARCINOMA  OF  THE   UTERUS 


creased  and  vary  much  in  the  size  and  shape  of  their  nuclei.  In  diffuse 
mahgnant  adenoma  the  cells  of  the  glands  are  increased  (Fig.  413), 
and  the  interglandular  tissue  is  made  up  of  round-celled  infiltration. 
The  presence  of  abnormal  proliferation  of  cells,  invasion  beyond  the 
confines  of  the  glands,  round-celled  infiltration,  and,  particularly,  the 
formation  of  definite  cancer  nests  must  be  sought  for  microscopically. 


Fig.  412 


Hyperplastic    endometritis    with    interstitial     proliferation:     a,    hjpertrophied    uterine 
glands;  b,  proliferated  interstitial  cells;  c,  uterine  muscle. 

It  is  extremely  difl&cult  to  harmonize  many  of  the  microscopic 
pictures  of  the  endometrium  with  the  clinical  course.  Not  infrequently 
a  diflPuse  proliferation  of  the  mucosa,  characterized  by  glandular  hj^per- 
trophy  and  piling  up  of  glandular  cells,  is  observed  which  presents  a 
clinical  history  extending  over  ten  or  twenty  years.  These  conditions 
are  usually  classed  as  carcinoma,  and  from  the  microscopic  appearance 
alone  may  well  be  regarded  as  such.  This  condition  is  usually  observed 
in  women  near  the  menopause.     The  removal  of  the  uterus  results  in  a 


C.IRCISOM.I  or   THE   HOD)    nl     ///J.    l   l  l.Kl  S 


583 


curt.',  ;iiul  ii  piarnl  (.iin  t  tciiu  iits  ;iii-  olti  ii  doiu-  without  ni;it(ii;ill\  ajima- 
vatin<;  the  rate-  ot  ilcvcK)pnuiu.  Muir  is  otrtii  an  i\tLiisi\  t-  rhukciiinf^ 
of    tlie   nuiscular   hiytr,  ami    tlic   i"cstiiil>lancc-   to   rhc   adi-uoinv  ouiatous 

Fig.  4'3 


^..^^rk^-:!"- 


..vfA  ■ 


<i£fi^ 


"^^ 


-1 


^^^si^A)^?^^  '%^l. 


Malignant  adenoma  of  the  uterus. 


Fig.  414 

"Sf\ 

T&^'"'^  lh"f» 

Carcinoma  of  the  bodv  of  the  uterus. 


584 


CARCINOMA  OF  THE  UTERUS 


uterus  is  sometimes  very  close.  In  several  cases  in  my  experience  the 
conditions  were  associated.  Schultz^  regards  these  changes  in  the  endo- 
metrium as  precancerous,  a  view  which  harmonizes  very  well  with  the 
clinical  course.  A  careful  comparison  of  the  microscopic  appearance 
and  the  clinical  history  of  these  cases,  it  seems  to  me,  must  lead  to  a 
readjustment  of  our  ideas  of  carcinoma  of  the  body  of  the  uterus. 

Contrasted  with  this  condition  is  that  in  which,  after  years  of  meno- 
pausal amenorrhea,  hemorrhage  begins.     The  first  apparent  structural 

Fig.  415 


^^^H^-^'''' 

^ 

■ 

^^^^■F^i 

-» 

^^^H 

^^^■b  / 

■'\ 

^^^^^^^1 

>._7/- 

\  '^^^1 

^^^. 

^ 

M 

^^^^^^^H 

% 

Carcinoma  of  the  body  of  the  uterus. 

change  is  the  appearance  of  nodules  in  the  mucosa,  which  are  hard  and 
friable,  and,  on  microscopic  examination,  proliferation  can  be  made 
out  in  the  cells.  Within  a  year  or  two  the  uterine  musculature  is  every- 
where invaded  (Fig.  414),  and  the  growth  breaks  down  (Fig.  415). 
The  infiltration  extends  also  through  the  musculature,  and  carcinoma- 
tous nodules  appear  upon  the  peritoneal  surface  and  in  the  broad  liga- 

^  Ztschr.  f.  Geburtsh.  u.  Gynak.,  1909,  Hx,  16. 


c.iRcisoM.i  OF  rill-  lionr  or  riih:  i  ti-ris 


:)S5 


nuiit  I'i^.  416).  Till-  ih;in[j,(s  111  ii  II  t  \  pi-  iiiid  the  disposition  to  iiuiulr 
the  suirouiiclin^  tissm-  ;iif  imu  h  ^rcatt-r  tlum  m  the  prici-dinj;  type. 
\hv  hroiid  li^anuius  :irc  in\;i(U(l  (itiirc  :is  i;iil\  and  glandular  nic-tastasis 
is  ;is  |iroMipt  as  in  i(  r\  ir;il  r;i!i,inoni.i.  I  his  t\pc*  should  i>i-  separated 
tioni  tin-  pii  (.(.ilinL;  ^loiip,  w  Imli,  w  hill- mKi()si-o|)uall\  1  cscnililin^  carci- 
noma, is  not  smh  clinu;ill\,  tholl^h,  like  liind-adcnoinas  of  the  breast, 
It   may   Ih-cijiuc   so. 

Fic.  416 


Carcinoma  of  the  fundus.    A  large  nodule  within  the  uterine  cavity  and  numerous 
nodules  beneath  the  peritoneum. 


Symptoms. — In  general,  carcinomas  of  the  body  of  the  uterus  occur 
at  a  later  age  than  those  of  the  cervix.  Hemorrhage  after  the  meno- 
pause is  the  cardinal  symptom.  Occasionally  there  is  an  ichorous 
discharge  great  enough  to  command  the  attention  of  the  patient  before 
the  advent  of  hemorrhage.  Pain  and  cachexia  almost  never  precede 
hemorrhage.  Upon  examination  the  uterus  is  uniformly  enlarged 
and  usually  it  is  approximately  the  size  of  a  parous  uterus  or  larger,  a 
marked  contrast  to  the  uterus  of  the  menopause.  It  ma\'  be  slighth* 
tender,  but  is  smooth  and  movable  unless  secondary  masses  extend 
beyond    the   uterus.      Hemorrhage   and    discharge    usually   weaken    the 


586  CARCINOMA  OF  THE  UTERUS 

patient  before  such  secondary  nodules  appear.  Only  rarely  does  the 
growth  extend  down  the  cervical  canal  so  far  that  it  may  be  seen 
through  the  vagina. 

Diagnosis. — Recurrence  of  hemorrhage  after  the  menopause  always 
demands  exploration  of  the  body  of  the  uterus.  In  carcinoma  the 
cavity  is  filled  with  a  friable  granular  material,  which  crumbles  under 
the  light  pressure  of  the  curette,  and  hemorrhage  is  apt  to  be  severe. 
These  findings  are  characteristic,  and  the  microscope  confirms  the 
clmical  diagnosis. 

Exploration  of  the  uterus  after  the  climacteric  amenorrhea  easily 
leads  to  a  diagnosis  when  carcinoma  is  present.  The  friable  material 
removed  by  the  curette  is  not  imitated  by  anything  else,  and  its 
appearance  at  once  justifies  radical  operation.  The  entire  mass  should 
not  be  curetted  away  at  exploration  because  of  the  added  danger  of 
dissemination. 

Differential  Diagnosis. — Carcinomas  of  the  fundus  which  occur  before 
the  menopause  are  likely  to  be  confused  with  a  number  of  conditions 
from  which  they  can  be  distinguished  without  difficulty.  The  chief 
symptom  of  these  is  profuse  and  more  or  less  continuous  hemorrhage. 
These  conditions  may  be  taken  up  in  the  order  of  their  frequency. 

1.  Adenofibroma. — These  are  characterized  by  hemorrhage  and 
uniform  enlargement  of  the  body  of  the  uterus.  They  never  bleed  after 
the  menopause.  Usually,  there  is  a  history  of  many  years'  duration 
and  often  of  numerous  curettements.  The  size  and  density  of  the 
uterus  often  suggest  the  presence  of  the  fibromuscular  increase.  The 
curettement  may  remove  thick  masses  of  mucous  membrane  which 
resist  the  curette,  but  the  material  is  never  dense  and  friable,  as  in  carci- 
noma. Examination  of  the  scrapings  shows  a  proliferated  mass  of 
glands,  without,  however,  the  cellular  anaplasia  of  carcinoma.  As  a 
final  resort  in  diagnosis,  hysterotomy  with  inspection  of  the  interior  of 
the  uterus  may  be  employed.  This  maneuver  must  usually  be  followed 
by  removal  of  the  uterus  in  order  to  stop  the  bleeding.  Most  of  the 
literature  on  this  subject  is  so  indefinite  that  but  little  reliance  can 
be  placed  upon  it.  This  is  particularly  true  of  that  previous  to  the 
writings  of  Cullen.  In  the  hght  of  his  important  work  the  entire  subject 
of  differentiation  between  fundal  carcinoma  and  fibro-adenoma  must 
be  revised. 

2.  Polypoid  Endometritis  (Fig.  417). — Our  notion  of  the  inflam- 
mations of  the  uterine  mucosa  have  undergone  such  changes  since  the 
work  of  Hitschmann  and  Adler^  that  great  caution  must  be  exercised 
in  the  discussion  of  this  subject.      It  is  estabhshed,  however,   that  in 

Ztschr.  f.  Geburtsh,  u.  Gynak.,  1907,  Ix,  63. 


c.iRcixoM.i  or  THE  lioDY  or  riir  irrRi's 


ns- 


(.•(.ituin  ooiulii  ioiis  tin  miuos;!  jm  olitiiwiis  ;iiul  toiins  ilmk.  masses 
which  pioiirt  nioic  oi  hss  iiiio  the  cavit\'  ot  tlie  urciiis.  Ih  iii<»i  rhage 
hctoii'  rht-  iiuii()p:uisi-  is  thi-  thirf"  symptom,  though  this  niiil  not  be 
unat.  I  !u-  cimrti.-  brings  forth  a  soft  sponj;y  mass  not  at  all  c-omparable 
with   the-  ilihiis   Hinoxtil   iii  (.aixiimma. 

^.  OiiiiK  I  ^  I'l  s  ()!•  Kndomkiritis.  Otiur  forms,  paiticulariv  that 
followiiii;  ahoiiioii,  ha\c  often  lieen  tiiistakeii  tor  tiiiidal  eareinoma, 
aitlioutih  persistent  hmioiihaue  is  the  ()iil\  s\  nii)ti)m  the\  ha\c-  iii 
eoinnion.       ihi-    softness    of   the    mateiial    hroii.uht    out    hy    the    curette 

hears    no   companscHi     to    the 


Kk;.  417 


fragile  hardness  of  carcmoma. 
The  hypertrf)phiecl  and  h\  pei- 
plastic  glands  ha\e  been  con- 
fused with  mahjiiiant  prolifer- 
ation. I  he  glandular  changes 
incident  to  the  decidual  forma- 
tion convey  the  mipression  (jf 

Fig.  418 


Polypoid  endometritis. 


Cervical  polyp. 


hyperplasia,  which  is  heightened  by  the  changes  in  the  cell,  which, 
losing  their  columnar  form,  become  oval.  The  chromatin  is  decreased 
proportionately;  there  is  no  evidence  that  the  cellular  infiltration  when 
present,  is  other  than  that  of  inflammation. 

4.  Submucous  Fibroids  (Fig.  418). — Fibroids  approaching  the  mu- 
cosa or  projecting  through  it  may  give  rise  to  hemorrhage,  and  when 
necrotic  may  give  an  ichorous  discharge.  With  these  tacts,  however, 
the  similarit}-  ends.  Usually  other  signs  of  fibroids  are  present.  The 
curette   does   not   reveal   the    fragile   tissue  of  carcinoma.      In   case  of 


588  CARCINOMA  OF  THE  UTERUS 

doubt  the  cervical  canal  may  be  widely  dilated  and  the  fundus  palpated 
with  the  finger.  Hemorrhage  in  these  cases  does  not  occur  after  the 
menopause  has  once  become  established. 

Prognosis. — The  permanent  cures  in  operations  for  carcinoma  of 
the  uterus  ma}'  be  placed  at  approximateh'  20  per  cent,  of  those  that 
come  to  operation  during  the  first  stage,  although  man\'  operators 
regard  the  prognosis  as  much  less  favorable  than  these  figures  indicate. ^ 
When  it  is  remembered  that  about  one  in  five  cases  are  operable  when 
they  come  to  the  surgeon,  the  chances  for  cure  in  the  aggregate  are 
very  small.  It  is  generalh'  stated  that  fundal  carcinoma  presents  a 
vastly  better  prognosis  than  cervical  carcinoma.  I  am  convinced  that 
these  favorable  statistics  are  in  part  the  result  of  including  as  carci- 
nomas conditions  which  are  not  malignant.  The  duration  of  carcinoma 
when  not  treated  varies  from  two  to  five  years,  with  occasionally  cases 
that  exceed  these  limits.  Such  statistics  have  little  value,  because  the 
date  of  begmnmg  must  be  alwaj's  a  mere  guess. 

Treatment. — Palliative. — From  the  frequency  of  the  association  of  lacer- 
ations of  the  cervix  and  carcinoma  it  might  be  deduced  without  further 
consideration  that  repair  of  cervical  lacerations  and  excisions  of  erosions 
would  be  important  factors  in  prophylaxis.  It  is  impossible  to  determine 
in  advanced  cases  the  condition  of  the  cervix  before  the  disease,  but  in 
many  of  the  earl}^  cases  the  beginning  carcinoma  may  be  found  upon 
an  otherwise  normal  cervix.  Though  more  carcinomas  occur  in  parous 
women,  the  number  of  women  who  have  borne  children  is  greater  than 
those  who  have  not;  still  it  may  be  accepted  that  carcinoma  is  more 
common  in  parous  women.  The  accidents  of  labor  ma}-  be  regarded, 
therefore,  as  a  predisposing  factor  in  the  development  of  the  disease. 
There  is  little  evidence,  on  the  whole,  of  the  importance  as  an  etiological 
factor  of  laceration  alone,  because  other  associated  factors  previoush' 
enumerated,  such  as  discharges  and  circulator}-  disturbances,  have 
been  left  out  of  account.  To  recommend  the  repair  of  lacerations  or 
the  excision  of  erosions  merel}"  as  a  prophylactic  measure  does  not 
seem  to  be  warranted,  when  the  existence  of  other  probabl}-  more  im- 
portant factors  of  sexual  h}-giene  are  disregarded.  However,  these 
lesions  are  usuall}-  attended  by  s}"mptoms  in  themselves  to  require 
treatment,  and  the  repair  may  then  be  undertaken.  If  the  factor  of 
prophylaxis  is  of  importance,  the  patient  gains  the  double  advantage 
without  the  necessit}'  of  the  operator  assuming  the  responsibilit}'  of 
a  purely  prophylactic  excision. 

^  Klein  (Monatsschr.  f.  Geburtsh.  u.  Gynak.,.  1909,  xxix,  710)  places  the  cures  at 
3.6  per  cent. 


c.iRci \().\i.i  oi   rin:  Hoh)  or  iiii:  i  rj:ki  s  :)S<» 

Curative.  \suli-  hom  r;iil\  i;iclu;il  i(iiiu\;il,  tluic  is  no  (.iin-.  As 
in  ;ill  (i|ni  at  ions  tor  caicmonias,  tissiu-  about  rlu-  jiiowtli  shoiilil  In- 
If  moved  as  tiirU  as  possible.  (Ilaiulular  metastasis  bemj^  relatively 
late,  tbc  wide  remoNal  ot  rhi-  [hi  iiiteiine  tissue  is  of  prime  importance. 
Just  how  tar  this  sliouUi  In-  carriecl  is  a  (luestion  ot  wei^bmji  primary 
morralit\  a»iamst  prospects  ot  a  peiniaiuiu  cure,  and  each  operator 
must  ilicide  this  tor  himselt  in  each  particular  case.  Most  operators 
remo\  I-  tin-  parametral  tissue  as  tar  as  tin-  ureters  and  even  beyond. 
Less  than  this  can  scarcely  be  called  a  radical  operation.  A  few  remove 
the  greater  pai  r  ot  the  pel\  ic  connectivi-  tissue.  Ihe  immediate  mortality 
is  hifj;h  in  the  radical  operations  and  the  prospects  of  cure  correspond- 
injily  jjreater.  It  is  too  earl\'  to  compare  results  secured  by  the  \arious 
methotls. 

Most  -American  operators  prefer  to  operate  through  the  abdomen 
with  or  without  Hist  destroying  the  growth  through  the  vagina,  to 
lessen  the  chance  of  infection,  and  with  or  without  Hrst  making  a  vaginal 
cufF.  Man\  European  g\'necologists  operate  by  the  vaginal  route.  \\  ith 
the  newer  technique  advised  by  \\  ertheim  it  must  be  admitted  that  tissue 
wide  of  the  cer\i.\  may  be  satisfactoni)'  removed. 

Less  suffering  and  often  prolongation  of  life  would  result  it  a  more 
judicious  selection  of  cases  for  palliation  rather  than  radical  operation 
were  made.  In  many  of  the  cases  in  the  second  stage  where  a  high  degree 
of  surgical  skill  is  not  available  and  in  all  of  those  which  have  reached 
the  third  stage  palliatne  methods  will  be  the  treatment  of  choice. 

The  means  of  palliation  have  included  the  use  of  man\"  chemicals  and 
the  actual  cautery.  Martin^  lauds  the  actual  cautery.  Lnder  a  general 
anesthetic  the  necrotic  mass  is  removed  with  a  curette.  The  surface  is 
then  seared  over  with  the  actual  cautery.  The  cavity  remaining  is 
packed  with  gauze  saturated  with  ferric  chloride.  This  is  followed  b}' 
successive  packings  with  plain  gauze.  B}'  this  means  a  deep  destruction 
of  tissue  is  obtained.  The  use  of  acetone,  introduced  b}'  Gellhorn,  has 
in  my  hands  been  more  efficient  than  the  actual  cauterw  This  author- 
advises  its  use  after  the  following  manner:  The  cancerous  area  is  thor- 
oughly curetted  under  a  general  anesthetic  and  the  hemorrhage  con- 
trolled by  temporary  packing.  The  crater  is  then  engaged  in  a  tubular 
speculum  and  one-half  to  one  ounce  of  acetone  is  allowed  to  flow  in.  In 
order  to  better  keep  the  fluid  in  contact  with  the  diseased  surface  the 
patient  is  kept  in  the  Trendelenburg  position.  After  fifteen  to  thirty 
minutes  the  hips  are  low'ered  and  the  fluid  is  allowed  to  flow-  out  through 
the  speculum.     The  cavity  is  then  packed  with  a  strip  of  gauze  soaked 

'  Deutsch.  med.  WOch.,  1908,  xxxiv,  89. 
-  Amer.  Jour.  Obst.,  1909,  iix,  799. 


590  CARCINOMA  OF  THE  UTERUS 

in  acetone  and  the  vagina  protected  with  a  cotton  tampon.  Subse- 
quently the  treatment  is  repeated  without  a  general  anesthetic  and 
without  a  preliminary  curettage.  The  vulva  and  lower  portion  of  the 
vagina  may  be  protected  by  a  thick  coat  of  vasehne. 

By  these  means  the  patient  may  often  be  made  comfortable  for  a  year 
or  two  or  even  longer.  The  duration  of  the  treatment  is  dependent  upon 
results.  Usually  it  is  necessary  after  a  variable  period  to  repeat  the 
treatment.  A  return  of  the  fetid  discharge  or  of  hemorrhage  is  a  signal 
for  the  renewal  of  the  treatment.  Pain  likewise  is  often  relieved  for 
prolonged  periods  by  these  palliative  means. 

Radical  palliative  operations  are  sometimes  advised.  If  all  of  the 
primary  tumor  can  be  removed  this  may  be  permissible,  but  to  delib- 
erately cut  through  carcinomatous  tissue  seems  more  likely  to  hasten 
the  disease  than  to  retard  it. 


C  W    \  V  \    !•    R      X  X  X  I  X 

s^■Nc'^■^l().M.\  .mai.i(;m.m  (CWRcinoma  s^nc  ^  ri  \i.i:, 

DKCIDIOMA,   CilORIO-KlM'IIIKLIOMAj 

Undkr  this  head  has  been  described  a  pecuhar  tumor  which  arises 
from  tlie  fetal  products;  that  its  precise  histogenesis  is  uncertain  is 
indicated  by  the  multitude  of  terms  which  have  been  applied  to  it. 
There  is  now  <2;eneial  agreement,  howexei-,  that  the  rumor  is  tornucl 
by  prohteration  ot  the  cellular  elements  of  the  chorionic  \'tlh,  namel\', 
the  syncytium  and  the  cells  of  Lan^hans.  The  syncytial  layer  has  been 
regarded  b\'  some  as  the  jnoduct  of  uterme  serotma  (Kossman,  Lang- 
Hans),  and  by  others  as  the  product  of  the  endothelium  of  the  uterine 
vessels  (Freund,  Pfannenstiel);  but  it  is  more  probable,  and  is  now  gener- 
alh'  believed,  that  the  SA'ncytial  cells  originate  from  the  fetal  ectoderm. 
The  ]>anghans  layer  is  regarded  b}'  some  as  likewise  of  fetal  ectodermal 
origin  and  b}'  others  as  the  product  of  the  stroma  of  the  villi.  It  does 
not  seem  proper  to  class  s^mcytiomas  with  the  epithelial  tumors,  both 
because  of  their  uncertain  origin  and  because  they  deviate  widely  from 
the  usual  structure  and  life  history'  of  such  tumors,  in  that  the\"  have 
no  stroma,  and  that  they  metastasize  exclusively'  by  the  bloodvessels. 

The  product  of  conception  supplies  the  point  of  origin  of  these  tumors. 
More  than  one-half  of  them  follow  upon  hydatid  moles,  and  many  are 
preceded  by  normal  pregnancy  or  abortion.  It  is  true  that  a  number 
of  cases  are  reported  in  regions  where  fetal  products  are  not  likel\'  to 
occur,  but  it  is  quite  possible  that  in  these  cases  the  tumors  develop 
either  from  congenital  misplacements  or  that  other  conditions  have 
been  mistaken  for  sync^tioma.  Findley^  reports  twent^'-one  cases  of 
this  kind,  but  Borst  questions  the  diagnosis  in  such  cases. 

Corresponding  to  the  dual-cell  layer  covering  the  villi,  two  varieties 
of  tumor  have  been  recognized;  but  both  types  are  present  in  nearly 
every  case,  so  that  a  division  into  two  groups  is  superfluous.  The  cells 
of  S3'ncytial  origin  are  disposed  in  large  protoplasmic  masses  containing 
numerous  o\al  nuclei  (Fig.  419  and  420).  The  protoplasm  is  vacuolated, 
sometimes  to  such  an  extent  that  it  appears  as  a  network.  The  nuclei 
are  distributed  irregularh',  and  are  oval,  rich  in  chromatin,  and  are  fre- 
quently in  process  of  mitosis.     The  nutriment  of  these  masses  seems 

^  Palmer  Findley,  Jour.  Amer.  Med.  Assoc,  1904,  xliii,  1351. 


592  SYNCYTIOMA  MA  LIGNUM 

to   be   derived   from   the   periphery,   there   being  no   distinctly   formed 
bloodvessels. 

Surrounding  these  cells  is  more  or  less  fibrinous  tissue  containing 
in  its  meshes  free  or  coagulated  blood,  mononuclear  cells,  leukocytes, 
and  cells  of  the  Langhans  type.  The  last  named  are  small  and  well 
defined  with  a  clear  cytoplasm.  The  nucleus  is  small,  round,  and  poor 
in  chromatin.  In  some  tumors  the  Langhans  cells  predominate  or  they 
may  even  make  up  the  entire  tumor.  This  is  particularly  Hkely  to  be 
true  of  those  which  invade  the  uterine  muscle. 


i  4 


^Mm 


Syncytioma  of  the  uterus:  a,  blood  spaces;  b,  syncytial  masses. 

When  syncytiomas  are  growing  in  the  interior  of  the  uterus  they 
are  fungiform,  but  when  they  extend  into  the  uterine  muscle  they 
cause  a  general  enlargement  which  may  be  symmetrical,  but  is  more 
often  irregular.  When  they  develop  in  regions  apart  from  the  original 
site,  they  are  rounded  tumors  which  when  near  the  surface  ulcerate 
early  and  form  fungus-like  masses.  This  is  more  likely  to  occur  when 
the  syncytial  elements  predominate. 

Macroscopic  Appearance.  —  Syncytiomas  on  section  are  mottled 
gray  and  red,  on  account  of  the  intermixture  of  the  syncytial  masses 
and  blood  clot.     The  contrast  is  less  marked  when  the  Langhans  cells 


SECOND.IR)   (:ii.i.\(:i:s  /.\  .s}'.V(;)'77o.\/./  m.ilicmm  593 

predominate.  'I'lie\'  are  ver\'  fVial>li ,  ami  icsc  iiiMi-  clc-^iiui  atiil  placi-ntal 
cissiie.  I  he\  hlicil  iasil\  ,  hoth  s|i()ntaiu<)usl\  ami  on  roucli.  I  hese 
riiuUiuMis,  rojietlur  uith  dun  (.lisposition  to  laily  and  widespread 
nu  tastasis,  ixplain  tluir  rapidly  tatal  course. 

Secondary  Changes.  Because  of  the  lack  of  special  Mood  supply 
ami  rlu'  triable  snucnue  rluy  under;io  necrosis  readily,  latry  degenera- 
tion and  secondary  intection  usuall)'  occur  and  aggravate  the  fatality 
ot    the    ilisease. 

Fig.  420 


Metastasis  is  always  by  the  blood  stream  and  most  frequently  in 
the  lung,  brain,  Hver,  spleen,  and  bone.  The  explanation  of  the  trans- 
plantation by  the  blood  stream  in  the  absence  of  a  definite  blood  supply 
lies  in  the  fact  that  the  tumor  sends  hnger-like  processes  directly  into 
the  bloodvessels  of  the  uterus,  in  this  \va\-  imitating  the  normal  villi. 
The  lymphatics  are  never  involved.  Characteristic  of  this  class  of 
tumors  is  the  disposition  to  form  retrograde  metastases.  This  peculiarity 
has  been  thought  to  explain  the  very  common  metastases  in  the  vagina, 
38 


594  SYNCYTIOMA  MA  LIGNUM 

but  it  is  questionable  if  they  should  be  accounted  for  in  this  way.  Veins 
from  the  uterus  communicate  freely  with  the  vaginal  plexus,  and  the 
vagina  might  even  by  direct  metastasis  be  the  first  seat  of  lodgement 
of  fragments  from  the  uterus.  Busse^  and  Davis  and  Harris-  report 
cases  of  syncytiomas  in  distant  parts  with  uterus  and  adnexa  not  in- 
volved, and  a  number  of  cases  have  been  reported  by  others  in  which 
syncytiomas  were  found  in  the  vagina  and  lungs  without  there  being 
any  tumor  in  the  uterus.  These  cases  are  sometimes  explained  by  the 
supposition  that  the  uterine  tumor  had  been  extruded,  with  the  result 
that  a  cure  was  effected  in  that  region.  Another  explanation  depends 
on  the  proved  fact  that  villi  ma}^  grow  into  the  blood  sinuses  in  normal 
pregnancy,  and,  being  broken  off,  may  be  carried  to  remote  parts  of  the 
body  (Veit).^  This  usually  causes  no  harm,  but  may  explain  the  occur- 
rence of  apparently  primary  tumors  in  regions  remote  from  the  uterus. 
It  is  a  curious  fact  that  sometimes  metastatic  nodules  disappear  when 
the  mother  tumor  has  been  removed.  The  body  has  apparently  the 
power  to  overcome  the  metastatic  nodules,  but  not  the  primary  tumor, 
and  It  has  been  assumed  that  this  is  brought  about  by  antibodies  which 
are  produced  by  the  parent  tumor,  and  which,  when  it  is  removed, 
are  able  to  overcome  the  metastatic  nodules. 

Diagnosis. — Macroscopic. — The  history  of  profuse  hemorrhage  follow- 
ing abortion  or  labor  at  term  should  always  suggest  syncytioma.  If 
disturbance  follows  the  expulsion  of  an  hydatidiform  mole,  the  presence 
of  syncytioma  is  probable.  When  small,  the  tumor  may  be  confined 
to  the  cavity  of  the  uterus  and  is  accessible  to  the  curette  or  palpating 
finger  only,  or  the  wall  of  the  uterus  may  be  infiltrated  in  such  a  manner 
that  the  curette  may  not  bring  away  characteristic  tissue.  In  that 
event  a  general  enlargement  of  the  uterus  not  otherwise  accounted  for 
may  be  the  only  physical  sign  apparent.  This  is  most  likely  to  be  the 
case  in  the  Langhans  type.  Usually,  however,  fungoid  masses  project 
into  the  cavity  or  even  from  the  cervix  which  from  their  friable  nature 
and  mottled  appearance  are  unmistakable.  Nodules  in  the  vagina, 
ulcerated  or  not,  may  exist  with  or  without  disease  within  the  uterus. 
Retained  placental  tissue  may  give  the  clinical  and  macroscopic  evidence 
of  syncytioma,  and  fibroids  and  corporeal  carcinoma  may  cause  confu- 
sion at  times. 

Microscopic. — In  many  instances  the  microscope  alone  can  give  a  posi- 
tive diagnosis.  The  syncytial  tissue  is  easily  recognized  by  the  large 
vacuolated  protoplasmic  masses.     Hydatid  rests  may  simulate  it  very 

1  Miinch.  med.  Woch.,  1902,  xlix,  1588. 
^  Davis  and  Harris,  Amer.  Jour,  of  Obst.,  xlii,  1900,  i. 

^  J.  Veit,  Das  Deciduoma  Malignum,  Handb.  der.  Gynakologie,  Bergmann,  Wies- 
baden, iii,  533. 


Tki:  11  \ii:\r  oi  sym:yi loM  I  \i  ii.k.m  m  .')!):> 

c"l()Si.'l\  ;iiul  ;iss<)ci.i  1  (  il  i  oiuli  I  k  )iis  ni.i\  li.i\c  to  he  t(  msulci  iil  to  ;iul  iii 
tin-  clirtticiui.it  iDii.  ImuIoiiu  1 1 II  IS  tollowm;^  ;il)oiti()ii  in  uhuh  ilioiioiiic 
\illi  li.i\i-  l>ic  n  i(i.im((l  m;i\  cause  conlusion.  I  siialh  ,  lu»\\t\ti,  tin- 
puiuir  IS  so  pLiiii  wluii  the  ciist-asc  is  ;ierii:ill\'  prt-sciH  iIkii  no  doiiht 
i-xists.  I  hf  l.:in<2,li;ins  i  \  pt  siimihnis  the  s;m-oni;is  close  1\  in  inuio- 
sct)pic  ;i|ipt;ii;incc,  ;iiul  it  is  iisii;ill\  tin-  cliim;!!  conisc  iIkii  piisciits 
us  oiii  hist  cliic.  I  lu-  (litinitf  oiiiliiit  of  ilu  cells  aiul  rlu-  clear  proto- 
plasm ami  the  lack  oi  small  i  lim-w  alUd  l)loo(l\c-sscls,  when  taken  in 
conjunction  wiih  tin-  cliimal  tiiulin^s,  arc  suHicu-nr  for  a  diatiiiosis. 

Prognosis.  llu'  fact  that  in  Indaiiil  mole  ihc  microsco|iic  [Picture 
of  s\  nc\tioma  ma\  he  present,  and  that  in  50  per  cent,  of  hydatid  moles 
a  nialiji,nant  condition  develops,  obliterates  an\'  sharp  di\idin^  Ime 
between  the  two.  It  follows  that  the  prognosis  is  vanalilt  .  Some 
tumors,  especially  those  in  which  the  Langhans  cells  predominate,  show 
little  disposition  to  rapid  <2;r(nvth  and  metastasis.  On  the  other  hand, 
and  especially  when  the  sync\  tial  element  is  greatest,  the  growth  may 
be  excessivel)'  rapid  and  lead  to  earl\'  metastasis.  .^Ithout^h  there 
seems  to  be  some  relation  between  the  degree  of  malignancy  and  the 
prevailing  histological  t^pe,  the  microscopic  evidence  as  to  which  cell 
type  prevails  cannot  be  used  as  the  basis  for  prognosis  in  a  concrete 
case.  The  probability  of  cure  is  dependent  upon  the  stage  of  the  disease 
when   treatment  is  instituted. 

Treatment. — Because  one-half  of  the  cases  of  hydatid  moles  develop 
into  s\ncytioma,  it  has  been  proposed  to  perform  a  prophylactic  hysterec- 
tom}'  in  all  cases  of  this  disease.  This  radical  position  has  not  become 
popular.  When  syncytioma  is  present,  if  the  tumor  is  confined  to  the 
uterus,  a  h3'sterectomy  should  be  done;  even  when  it  is  not  possible  to 
remove  all  the  metastatic  foci,  the  removal  of  the  primary  tumor  is 
followed  b\'  recover}'  in  a  few  instances.  This  is  true  even  when  there 
are  lung  metastases.  Frequenth',  patients  are  extremely  anemic  when 
they  first  present  themselves  for  examination.  In  such  cases  a  pre- 
liminary cauterization  ma}'  check  the  hemorrhage  and  allow  the  patient 
to  recuperate  sufficiently  to  undergo  a  radical  operation  at  a  later  date. 


CHAPTER    XL 

TUMORS  (CYSTIC  AND  SOLID)  OF  THE  OVARY,  TUMORS 
OF  THE  FALLOPIAN  TUBES 

General  Conception. — The  ovary  furnishes  better  material  for  study 
of  the  gradations  from  benign  to  malignant  tumors  than  any  other 
organ.  Cystic  tumors  may  be  found  which  fall  into  a  series  showing 
the  transition  from  the  simple  proliferative  cysts  through  the  papillary 
cj^stomas  to  the  malignant  type.  Parallel  to  this  histological  gradation 
are  the  physiological  changes  from  the  benign  cysts,  in  which  the  secretory 
activity  of  the  epithelium  predominates,  to  the  malignant,  in  which  the 
entire  energy  of  the  cells  is  expended  in  reproduction.  The  solid  tumors 
show  a  similar  gradual  transition;  the  border-line  between  fibromas 
and  sarcomas  is  not  well  marked,  and  histologically  the  differentiation 
is  often  a  matter  of  opinion;  on  the  other  hand,  some  sarcomas  of  the 
ovary  are  not  surpassed  in  malignancy  by  any  other  tumor  of  the  body. 

It  is  a  matter  of  convenience  to  divide  ovarian  tumors  into  the  cystic 
and  the  solid. 


CYSTIC   TUMORS   OF   THE   OVARY 

Cysts. — Cysts  of  the  ovary  include  conditions  varying  from  slight 
disturbances  in  the  evolution  of  the  Graafian  follicles  to  tumors  huge 
in  size,  such  as  the  retention  cysts,  or  malignant  in  character,  such  as 
the  best-marked  examples  of  proHferative  cysts;  the  cysts  may,  therefore, 
be  considered  conveniently  under  two  heads,  retention  and  proliferative. 

Retention  Cysts. — Luteal  Cysts. — These  cysts  result  from  abnormal 
involution  of  corpora  lutea.  Some  authors^  regard  them  as  of  frequent 
occurrence,  but  if  only  those  are  reckoned  which  contain  demonstrable 
luteal  rests,  they  are  certainly  much  rarer  than  the  follicle  cysts.  They 
vary  in  size  from  a  hazelnut  to  a  walnut,  or  even  as  large  as  an  adult 
head,  and  have  thick  corrugated  walls  (Fig.  421),  which  are  formed  from 
several  layers  of  cuboidal  cells  containing  pigment  within  and  between 
them,  the  cells  resting  on  a  vascular  layer  of  fibrous  tissue.  The  contents 
may  be  thin  and  clear  or  thick  and  reddish  or  yellowish  from  previous 

^  Nagel,  Arch.  f.  Gynak.,  1887,  xxxi,  327. 


CYSTIC  riM(JRS  Of    Till:  (Jl  .IRY 


59; 


luinoi  I  h;i<;i-;  soiiuriim-s  iluii-  is  ;i  j;r;iiuil;ii  dihriN  iiKiclt-  uji  ot  aii  emul- 
sion ot  tarriU  cU-^riu  r;ittil  cills.  Mood,  ;iiul  serous  exudiite.  1  he\'  are 
usuall\-  solitan',  but  iiia\'  be  nudtijile.  1  lu\-  indicate  a  chronic  ovaritis, 
and  result  from  a  disturbance  in  the  evolution  of  the  corpus  ha;mor- 
rha^icum. 


I'u;.  421 


/^  1^  ^' 


Fig.  422 


Luteal  cyst  of  the  ovary. 


Follicle  cyst  of  the  ovarv 


Follicle  Cysts^  (Fig.  422). — Under  this  caption  are  included  cysts 
varying  in  size  from  a  pea  to  a  walnut,  or  even  larger,  which  are  formed 
from  unruptured  Graafian  follicles.  The  walls  are  smooth  and  com- 
posed of  dense  fibrous  tissue,  with  few  nuclei;  they  ma}'  be  without 
epithelium,  or  ma>-  be  lined  with  flattened  or  columnar  epithelium. 
The  cystic  contents  are  usualh"  thin  and  clear,  but  may  rarely  be  clouded 
from  hemorrhage.  Follicle  c^sts  result  from  thickening  of  the  tunica 
albuginea  by  a  preexisting  ovaritis  or  periovaritis,  which  prevents  the 
follicle  from  rupturing.  When  the  cysts  are  small  they  project  from 
the  surface  of  the  ovar}',  but  when  large  the  ovary  is  pushed  aside  and 
mav  even  appear  as  a  thinned-out  disk  at  the  base  of  the  cyst.  Pfannen- 
stiel  believes  that  cysts  indistinguishable  from  these  may  be  formed 
as  the  result  of  old  hemorrhages  into  the  ovary  (hematoma  of  the 
ovary   Fig.  423). 

Similar  to  the  follicle  CA'sts  is  the  so-called  c\stic  degeneration  ot  the 
ovar\-.  In  this  condition  the  ovary  is  studded  with  peanut  to  hazelnut- 
size  cysts  (Figs.  424  and  425)  embedded  in  or  projecting  slightly  from 
the  surface.    The\'  have  thick  walls  and  are  filled  with  a  clear  or  straw- 


1  C.  Gebhard,  Pathologische  Anatomie  der  Weiblichen  Sexualorgane,  Hirzel,  Leipzig, 
1899. 


598 


TUMORS  OF  THE  OVARY 


colored  fluid,  which  is  under  marked  tension.    The  condition  is  probably 
the  result  of  fibrotic  changes  in  the  tunica  albuginea. 

Fig.  423 


Hematoma  of  the  ovary. 


Fig.  424 


Fig.  425 


/ 


7 


Follicle  cyst  of  the  ovary. 


Follicle  cyst  of  the  ovary. 
Cross-section. 


Not  infrequently  cysts  similar  to  the  folhcle  cysts  are  associated 
with  dilated  tubes  and  are  continuous  with  them,  so  that  tube  and  ovary 
enclose  a  common  cavity.  The  contents  are  similar  to  those  of  the  follicle 
cysts.    They  are  developed  by  an  inflammatory  union  of  tube  and  ovary 


CYSTIC  nwKjRs  or  riii:  oi  iry 


599 


in  iuht)t)\  ;ii  i;m  ;i!>scfssi-s.      I  lu-  rysric  toiUints  iiic  soimt  lines  |)i-H()clu;ill\ 
discharjiiil  tliioutih  tlu   tuin-  iiiio  the  iirt-rus. 

CMinii;ill\  ,  \\\v  iitiiition  c\sts  ;iir  liinircil  in  ^rowtli  ;inil  remain 
station. II  \  attn  aitainini:  a  ciitain  si/.c  I  lu\'  luvc-r  cU-vi-lop  info  otlu-r 
t\'pes  of  tiimois,  piodiui  iioiahli-  s\  in|iton)s,  iioi  iiiuliii;o  inali^inant 
chaniie. 

Proliferation  Cysts.  I  lu  imirdiiif:,  c\sts  arc  toiiiKcl  by  scmu-  tlistmh- 
aiUT  in  tlu-  exolutioii  of  noinial  jirocesses,  and  are,  therefore,  iu)t  neo- 
plastic in  (.■haractei .  This  tiioup,  on  the  contrar)',  is  characterized  h\' 
an  activi'  growth  of  the  epithelium.  1  he  degree  of  activity  these  cells 
manifest  \aries  markedl\  ,  some  heing  active  both  physiologically  and 
in  proliferation,  while  others  manifest  almost  their  entire  activity  in 
cell  multiplication.  For  this  reason  it  is  desirable  to  divide  them  for 
discussion    into   the   simple   proliferative   cysts   and    the   c\stadenomas. 


Fig.  426 


^ 


Proliferative  cyst  of  the  ovary. 


Simple  Proliferative  (Fig.  426). — In  this  t\pe  the  epithelium 
takes  an  active  part  in  the  growth  of  the  tumor,  but  its  chief  activity 
is  manifest  in  an  increased  secretion,  cell  proliferation  being  confined 
to  a  degree  necessar\"  to  line  the  cyst  wall  as  it  increases  to  accommodate 
the  collecting  fluid.  The  correctness  of  separating  this  group  from  the 
follicle  c\"sts  ma\'  well  be  questioned,  for  in  size  and  structure  they 
are    not    always    easily    distinguishable    from    them.      In    pathogenesis. 


600  TUMORS  OF  THE  OVARY 

however,  they  are  different;  the  foUicle  cysts  result  from  an  interstitial 
change  in  the  ovary,  and  epithelial  activity,  if  any  is  present,  is  secondary; 
but  in  the  proliferative  cysts  the  epithehal  activity,  though  slight  in 
degree,  is  primary  and  the  connective  tissue  of  the  ovary  is  normal  or 
only  secondarily  affected. 

These  cysts  arise  from  Pfliiger's  columns,  which,  on  account  of  some 
disturbance  in  development,  have  failed  to  produce  normal  follicles. 
This  explanation  was  offered  by  v.  Kahlden,^  who  was  able  to  demon- 
strate such  developmental  disturbances  in  numerous  ovaries.  The 
cysts  are  unilocular,  or  rarely  multilocular,  with  walls  which  are  smooth 
without  and  usually  smooth  within,  though  occasionally  there  is  a 
moderate  degree  of  papillary  formation  in  the  interior.  Externally 
they  are  covered  by  the  germinal  epithelium  of  the  ovary,  and  within 
are  lined  with  columnar  or  cuboidal  cells,  or,  when  the  pressure  within 
the  cyst  becomes  great,  by  flattened  epithelium.  The  cyst  wall  proper 
is  composed  of  fibrous  tissue  poor  in  nuclei,  containing  a  varying  number 
of  bloodvessels,  and  is  rarely  more  than  2  mm.  to  3  mm.  in  thickness. 

Proliferative  cysts  are  usually  the  size  of  an  orange  or  larger,  or  may 
attain  huge  dimensions.  When  they  are  small,  the  ovary  may  be  seen 
flattened  out  at  the  base;  in  the  large  ones  all  trace  of  the  ovary  may 
be  lost.  The  cystic  contents  are  clear  or  slightly  yellowish,  but  may  be 
red  when  hemorrhage  has  occurred;  ordinarily  the  cystic  content  is 
unirritating,  and  should  the  cyst  rupture,  as  it  not  infrequently  does, 
the  fluid  is  absorbed  without  reaction  on  the  part  of  the  peritoneum. 

Clinically,  these  tumors  are  slow  of  growth,  and  tend  after  a  time 
to  reach  a  maximum.  It  is  said  that  they  may  even  regress  through 
the  absorption  of  the  cystic  contents;  the  cyst  wall  may  rupture  and 
spontaneous  cure  result  (Pfannenstiel). 

In  harmony  with  the  evidence  of  hmited  epithelial  proliferative 
capacity  the  growths  rarely  become  large  enough  to  endanger  life,  and 
they  never  show  disposition  to  malignant  change.  They  are  usually 
found  incidentally  in  the  search  for  other  maladies,  though  when  large 
they  may  reach  clinical  dignity. 

Cystadenomas. — In  these  tumors  the  epithelial  proliferation  is  in 
excess  of  that  required  to  line  the  cyst  walls;  they  belong,  therefore, 
to  the  true  tumors.  Their  origin,  like  the  preceding,  is  probably  from 
some  disturbance  in  the  development  of  the  ovary.  Waldeyer-  believes 
they  arise  from  epithelial  embryonal  rests  or  from  the  germinal  epithe- 
hum  of  the  ovary,  while  Steffeck^  believes  they  are  due  to  proliferation 

^  Ueber  die  Entstehung  einfacher  Ovarialcysten,  Fischer,  Jena,  1899. 

^  Arch.  f.  Gynak.,  1870,  i,  252. 

^  Ztschr.  f.  Geburtsh.  u.  Gynak.,  1890,  xix,  236. 


MuUilocular  Pseudomucinous  Cysiaclen^jma  of  ihe  Ovary. 


CYSr/C   71  MORS  or   Till,   ol    IRY  (101 

of  tin-  cpii  In  liiim  ol  ilu-  pi  mionlia  I  tollirlcs.  Ii  is  not  iiin-oiiiinon  to 
find  I'ohnnns  of  re!  Is  extending  some  tltpi  li  niio  i  Ik-  ovary  and  |)i  irnoniial 
tollicU'S,  tin-  ipitl)(IInin  of  winili  shows  cvuicnfc-  of  activity,  and  it  is 
possihK'  that  hoth  rxplanations  ai(  concrt;  tliou{;h  to  follow  citluT 
to  (levtlo|inu  nt  into  a  icco^nizcd  t  \  pt-  ol  tumor  is  besi-t  uitli  nianv 
ilirticultRS   as   \  ct    not    oNcrconu-. 

I  he  ipirlulial  activity  of  these  timiois  shows  j^reat  variation.  In 
sonii-  tlu-  ci  Miliar  iKvtIopnunt  is  ^reat,  while  others  are  characterized 
instiail  In  an  alnindancr  ot  secic-tion.  In  sonn  the  c«lls  loiin  new 
cysts  within  the  xsali  of  tin-  mother  cyst  (everting  cystadenonia),  or 
may  develop  by  forming  projections  into  the  cyst  cavit\'  (inverting 
c\'stadenoma).'  These  t\'pes  are  explained  as  dependent  upon  the  intra- 
c\stic  pressure;  w  lun  this  is  tricar  the  txxrnng  t\  pe  iisults,  and  when 
less,  the  inverting.  It  seems  more  likely,  however,  that  the  explana- 
tion is  to  he  found  rather  in  the  difference  in  proliferative  activity  of 
the  cells,  those  showing  great  activity-  forming  the  inverting  t\-pe  and 
those  less  active,  the  everting  type.  This  view  is  in  harmony  with  the 
clinical  course,  and  does  no  violence  to  the  anatomical  findings. 

In  addition  to  the  structural  differences,  cystadenomas  var\-  also 
in  secretor\'  activity'  as  to  both  amount  and  kind.  It  is  convenient  to 
divide  them  according  to  the  material  they  secrete,  namely,  pseudo- 
mucinous and  serous.  Each  of  these,  for  completeness,  may  be  divided 
again  into  the  everting  and  inverting,  the  former  corresponding  to  the 
glandular,  and  the  latter  to  the  papillary  cystadenomas  of  Waldeyer's 
classification. 

Pseudomucinous  Cystadenomas. — This  is  the  most  frequent  type 
of  ovarian  cystoma,  and  tends  to  attain  the  largest  size;  many  examples 
of  huge  tumors  are  to  be  found  in  literature.  In  former  times,  before 
surger\-  had  attained  its  present  state  of  development,  tumors  weighing 
one  hundred  pounds  and  more  were  not  infrequentl\'  observed.  These 
tumors  are  most  frequently  seen  during  the  child-bearing  period,  as 
might  be  expected  if  they  develop  from  primordial  follicles;  the  stimulus 
of  ovulation  would  be  well  calculated  to  develop  a  latent  tendency  to 
growth. - 

Pathology. — Macroscopic  Appearance. — These  tumors  are  spheroidal 
or  multilocular  (Plate  III),  depending  on  whether  the\'  are  made  up 
of  one  or  more  relati\'ely  large  loculi  or  daughter  cysts.  They  are  whitish 
or  grayish  white  where  the  wall  is  thick  and  bluish  where  the  wall  is 
thinner.     If  when  multilocular  the  secondary'  c^'sts  become  large,  lobules 

'  Pfannenstiel,  Leber  die  pupillonien  Gescliwiilste  des  Eierstockes,  Schumacher,  Berlin, 
1895;  Arch.  f.  Gynak.,  1895,  xlviii,  507. 

^  Olshausen,  Krankheiten  der  Ovarien,  Enke,  Stuttgart,  1885. 


602 


TUMORS  OF  THE  OVARY 


of  equal  size  may  be  formed;  instead  of  these  remaining  distinct,  the 
septa  may  rupture  and  a  common  cavity  result,  with  lobules  springing 
from  its  walls  at  the  site  of  the  former  partition.  When  the  new 
cysts  remain  unruptured  within  the  wall  of  a  large  tumor  they  present 
cavities  of  varying  size,  but  they  give  the  general  picture  of  glands 
(Plate  IV).  The  disposition  in  some  cases  to  form  secondary  cysts  is 
not  great  and  the  secretory  activity  may  balance  the  proHferative.  In 
other  instances,  tumors  in  the  main  independent  may  have  a  common 
attachment  at  their  base  (Fig.  427).  It  has  been  assumed  by  Pfannen- 
stiel   that   this   type   develops   from   rests   of  the  Wolffian  bod}/^,  while 

Fig.  427 


Multilocular  pseudomucinous  cystadenoma  of  ovary. 


Gebhard  believes  they  were  originally  independent  and  later  become 
confluent  by  pressure  atrophy  of  the  intervening  tissue.  One  specimen 
examined  by  me  seemed  to  be  formed  by  excessive  eversions  of  daughter 
cysts,  so  that  pedicles  attaching  them  to  a  common  base  alone  remained, 
the  primary  cyst  having  disappeared. 

More  striking  than  their  general  form  is  the  cyst  contents.  As 
the  name  indicates,  this  substance  has  the  appearance  of  mucin,  but 
actually  contains  none  of  this  substance.  It  varies  in  consistency  from 
a  thick,  gelatinous  material,  more  or  less  tenacious  to  fluid,  which  is, 
however,  never  without  demonstrable  tenacity.     The  color  is  usually 


PLATE   IV 


Cross-section  of  a  Pseuclomucinouis  Cysiadenoma  of  the  Ovary. 


cYsr/c  riMoks  or  riii.  oi  iry 


003 


Miiisli  wluit,  1)111  m.i\  In  vcllowish  or  hiownisli  or  c\in  l)l;ick  wlu-n 
lunioi  rlKitii-  h.is  t.ikiii  |)l.u«  .  I  lu  i  oiii  imuil  mass  is  iisuall\  divuKd 
iiuo  comivirmuiUs  l>\  Mpta,tlu-  r( mains  ot  former  cyst  walls,  so  that 
it  is  oliin  iu(.issar\  thai  tlusc  hi  rii|)tini(l  hcfore  the  c>'st  can  be 
rmpiiiil  of  its  coiUeiits.  iiu-  spiiihi-  (  Kiiuiit  ol  riiese  cysts  is  pseiido- 
imuin,'  ot  which  thiii-  arc  \aiioiis  lorms,  \ar\  iii^  m  alkahmr\  and  nitro- 
gen coiUenr.  .\cc()i"cliii^  to  IMamuiistuI,  tin-  ps(  ii(h)mutin  is  an  actual 
secretion  ot  the  cells.  C\ll  (le^:eneration  adds  hut  little  to  the  c\'st 
contents,  whiii'  luinoiiha,m-  ma\  he  so  ^lear  as  to  ohscure  tin-  primal)' 
suhsta  nee. 


•  Fic.  428 


„^^y^mn^ 


ii»»*W^, 


5 ''''.v.;  .'!,,'' '.v\"''.'  ■  ''.'•"■■•, 'c ''!<''-' ,^    .5';iV.' •'''''.' .-.■/'V,'''^  "i'*''?'' 


'if'i 


Wall  of  a  pseudomucous  c\'stadenoma  of  ovar}'. 

Microscopic  Appearance. —  The  cysts  are  lined  with  columnar 
epithelium,  with  the  nuclei  lying  near  their  base  (Fig.  428).  These  cells 
are  prone  to  undergo  fatt}'  degeneration  and  exfoliation,  and  numbers 
of  them  ma\'  usuall\-  be  found  in  the  c\'st  contents;  through  imbibition 
of  fluid  the\'  appear  as  large  round  cells  which  are  particularly  striking 
because  of  the  strong  acidophilic  properties  of  their  protoplasm.  The 
C3'st  wall  external  to  the  cellular  la\er  is  formed,  first,  by  a  layer  ot  loose 
connective  tissue  in  which  numerous  large  vessels  are  found;  external 
to  this  a  layer  of  dense  fibrous  tissue  with  few  nuclei,  and  be\ond  this 
a  Ia3er  of  flattened  epithelial  cells.  The  cyst  wall  varies  much  in  thick- 
ness,  beinH  in  some  of  the    loculi    with   more  fluid  contents  not  more 


'  Pfanntnstiel,  Arcli.  f.  Cyniik.,  l8qo,  xxwiii,  407, 


604  TUMORS  OF  THE  OVARY 

than  2  mm.  to  4  mm.  in  thickness.  On  the  other  hand,  at  the  base 
of  the  tumor  the  wall  may  be  much  thickened. 

Papillary  projections  may  form  within  the  cyst  by  epitheHal  pro- 
longations or  by  proliferations  of  the  fibrous  tissue  of  the  cyst  wall. 
They  may  be  imitated  by  the  remains  of  septa. 

Clinical  Course. — Pseudomucinous  ovarian  cysts  produce  mischief 
most  often  because  of  their  large  size;  they  are  often  without  notable 
symptoms  until  they  produce  evident  enlargement  of  the  abdomen. 
When  they  fill  the  abdomen,  nutritional  disturbances  occur,  and  when 
they  limit  the  movements  of  the  diaphragm  dyspnea  results. 

Sometimes  they  undergo  spontaneous  rupture,  and  the  cyst  contents 
escape  into  the  peritoneal  cavity.  The  peritoneum  may  react  by  in- 
flammation only;  or  cells  escaping  from  the  cyst  may  develop  upon  the 
peritoneum  and  give  rise  to  a  condition  called  pseudomyxoma  peritonei.^ 
Sometimes  in  the  rupture  of  the  cyst  hemorrhage  occurs,  which  may 
be  so  great  as  to  fill  the  entire  abdominal  cavity  with  blood.  When 
spontaneous  hemorrhage  occurs  there  is  always  a  probability  that 
malignant  degeneration  has  taken  place. 

The  most  frequent  accident  of  development  is  torsion  of  the  pedicle. 
In  from  20  per  cent.  (Schauta)  to  47  per  cent.  (Mickwitz)  of  the  cases 
of  ovarian  tumor  the  pedicle  becomes  twisted,  and  sometimes  the  uterus 
turns  with  it.  The  torsion  is  usually  at  least  180,  more  frequently 
360  degrees,  and  in  direction  usually  from  right  to  left,  that  is,  counter- 
clockwise. Tumors  with  long  pedicles,  particularly  dermoids  and  par- 
ovarian cysts,  are  most  likely  to  become  twisted.  Torsion  of  the  pedicle 
is  particularly  likely  to  take  place  during  pregnane}^  and  in  old  age, 
when  the  uterine  ligaments  are  lax.  The  cause  is  not  understood;  the 
varying  distention  of  the  intestines  and  increased  and  irregular  intra- 
abdominal pressure  have  been  named  as  causes.  The  torsion  is  most 
likely  to  take  place  when  because  of  its  size  the  growth  is  passing 
from  a  lateral  to  a  central  position.  It  may  be  sudden  or  gradual  or  a 
succession  of  sudden  movements. 

The  result  depends  on  the  degree  of  torsion  and  the  rapidity  with 
which  it  takes  place.  When  the  torsion  is  sufficient  to  prevent  a  return 
flow  of  the  blood  through  the  pedicle  the  most  frequent  accident  is 
hemorrhage  into  the  interior  of  the  cyst,  because  of  increased  permeabilit}^ 
of  the  vessel  walls  due  to  the  disturbed  nutrition.  This  is  followed 
by  a  stasis  of  the  blood  within  the  wall,  which  results  in  a  loss  of  the 
superficial  epithelium  and  subsequent  attachment  to  the  surrounding 
surfaces.      These    secondary    attachments    may    sustain    the    nutritive 

^  For  a  summary  of  the  relation  of  this  condition  to  ovarian  cysts  see  Schumann, 
Surg.,  Gyn.,  and  Obst.,  1908,  vi,  15. 


> 

Eh 

< 


CYSTIC  TUMORS  OF  THE  or.lRY  C.O'j 

su|>pl\  ot  ilii-  tumoi.  Attfi  till-  iin  ulaiioii  is  ustoiccl  the  adlu-sions 
iiia\'  hr  released.  It  (In  ;iiiii\  is  oiiliuk-d,  lucrosis  is  the  result.  This 
iiiriamiiiatory  react loii  is  due  to  local  iiiitation  from  the  distressed 
tissue,  and  not  to  I'tacterial  infection;  hut  sonietinies  hacteria  may  ^ain 
access.  I  hi'  |Hilule  may  hicome  cntiiily  se\iicd  and  the  tumor  mav 
take  attachment  to  the  omentum.  These  chanj^es  cause  a  peripheral 
peritt)mtis,  which  ^ives  rise  to  profound  irritation  of  the  entire  abdomen, 
with  the  accompanying  symptoms  (jn  the  part  of  pulse  and  temperature, 
rile  s\  iiiinoms  are  much  a<i;jj;ravated  if  miciohal  infection  is  added 
to  the  torsion  of  the  pedicK-.  This  accident  is  particularh'  likel\'  to 
happen  when  there  is  alreatly  a  slumheimji  inflammatory  lesion,  as  of 
the  appi-ndix  or  of  the  tube.  Infection  of  oxarian  c}'sts  ma\'  occur  in 
the  absence  of  torsion  of  the  pedicle;  but  in  this  case  rupture  of  the 
cyst  with  peritonitis  rarel)'  follows.  Instead,  the  interior  of  the  cyst 
usuall)'  loses  its  epithelium  and  becomes  converted  into  a  pyogenic 
membrane;  sometimes,  however,  a  fistula  forms  with  some  of  the  neigh- 
boring organs  (an  accident  particularly  likeh^  to  happen  also  in  the 
dermoids)  and  the  cystic  contents  escape. 

Malignant  Degeneration. — Pseudomucinous  cystomas  sometimes  be- 
come malignant.  This  ma}'  take  place  at  the  base  or  in  the  septa  of 
the  tumor.  The  wall  becomes  thickened,  forming  thick  brittle  or  tough 
masses,  within  which  fine  white  dots  can  be  made  out  with  the  naked 
e^e  (Plate  \).  These  white  points  are  necessary  to  a  diagnosis,  for 
the  capsule  may  be  much  thickened  without  there  being  any  malignant 
change.  Microscopically,  the  thickened  wall  is  seen  to  be  infiltrated 
with  epithelium,  forming  gland-like  spaces  or  more  or  less  solid 
nests  (Fig.  432).  The  epithelium  is  often  taller  than  that  lining  the 
benign  c^st  spaces,  and  stains  more  deeply;  often  there  are  mitotic 
figures. 

Serous  Cystadenomas. — The  preceding  group  is  characterized  by 
large  size  and  relatively  slight  intracystic  development  of  epithelium, 
while  this  type  rarely  attains  a  large  size  and  is  marked  by  extensive 
intrac\stic  development;  that  is,  the  inverting  t^-pe  predominates. 
The}'  occur  later  in  life  and  have  a  much  greater  tendcnc}'  to  malignant 
change.     1  hese  are  the  topical  papillar}'  c\'stomas  of  Walde\er. 

Pathology. — Macroscopic  Appearance. — Like  the  pseudomucinous 
t\pe,  these  ma}'  be  single  and  spherical  or  ovoid ;  or  composed  of  a  number 
of  loculi,  though  usualh'  fewer  than  in  the  other  variety  (Fig.  429). 
The  several  c}sts  ma}'  become  united,  leaving  onl}'  imperfect  partitions 
to  show  the  former  septa.  The  serous  c}'sts  ma}'  be  formed  like  the 
preceding  group  b}-  the  development  of  daughter  c}"sts  within  the  walls, 
but,  as  mentioned  before,  the  type  is  the  inverting  form  and  the  papillar}' 
projections  into  the  cavit}'  of  the  c}st,  forming  white  or  gra}ish  cauli- 


606 


TUMORS  OF  THE  OVARY 


Serous  cystadenoma  of  the  ovary. 


Fig.  430 


$0  4^r'^^§ 


o 


Serous  ovarian  cysts;  papillary  projections  into  the  cavity  of  the  cyst. 


CYSTIC  riMoRs  or  the  Ol  iry 


tio; 


tlowii-liki-  iiKissc-s,  are  clistiiKti\c  (I'lj;.  430).  Kacli  papilla  is  spluroul, 
Init  wluii  a  con^lonu rated  mass  is  fornud  it  accommoclatts  itself  to 
the-  pitssure  of  siii  loiiiulinti  notlules. 

!  Ik-  c\st  c'onttius  an-  charactt.ii/.t<l  h\  tlu-  ahscnct-  ot  psciulomiRin 
and  In'  tlu-  presence-  ot  a  lar^,f  amount  ol  alhiimm.  I  lu-  Hind  is  \ellowisli 
or  gicenisli  and  is  not  tenations.  I  Irmoi  rha^i-  int(j  the-  cysts  may  pro- 
duce a  brownish  or  black  Huid. 

Microscopic  Appkaranck.  IIh-  striking  factor  is  the  presence 
of  c\  lindrical  epithelium,  taller  than  that  lining  the  pseudomucinous 
cysts  and  with  rlu-  luicki  situated  near  the  base  '  Fi^.  431)-      1  he  struc- 


FiG.  431 


^^'Z 


Cells  lining  the  villi  of  a  serous  cvstadenoma  of  the  ovary. 


ture  of  the  fibrous  wall  is  similar  to  that  of  the  preceding  group.  The 
source  of  the  epithelium  is  still  undetermined.  Two  views  have  been 
advanced.  According  to  the  first,  it  originates  in  the  epithelium  ot 
the  tubes, ^  while  the  other  and  more  generally  accepted  theor\'  is  that 
it  develops  from  the  germinal  epithelium,^  or  from  either  this  layer  or 
the  Graafian  follicles.^  W  hen  the  papillary  formations  reach  the  opposite 
cyst  wall  erosion  results,  the  cell  contents  escape,  and  the  papillary  mass 
projects  into  the  abdominal   cavit\-.      In   this  wa\'  tumors  made  up  m 

^  Kossmann,  Monatsschr.  f.  G\nak.,  1895,  i,  97. 

-  Flaischlen,    Ztschr.   f.  Geburtsh.   u.  Gyniik.,   1881,   vi,   231;    Pfannenstiel,  Arch.   f. 
Gynak.,   1891,  xl,  363. 

'Williams,  Johns  Hopkins  Hosp.  Rep.,  1894,  iii,  i. 


608  TUMORS  OF  THE  OVARY 

part  of  cysts  and  in  part  of  papillary  masses  are  formed.  Of  great  prac- 
tical interest  is  the  disposition  of  these  to  occur  simultaneously  in  both 
ovaries. 

Clinical  Course. — Serous  cystadenomas  sometimes  suffer  torsion  of  the 
pedicle  and  sometimes  produce  symptoms  because  of  their  size,  as  in 
the  pseudomucinous  type.  Their  clinical  importance,  however,  depends 
on  their  disposition  to  malignant  change.  This  may  take  place  by 
the  infiltration  of  the  pedicle  (Fig.  432)  of  the  tumor,  but  usually 
the  papillary  formations,  after  they  become  exposed  by  the  rupture 
of  the  cyst,  produce  contact  metastases  upon  the  neighboring  peritoneal 
surface  (Fig.  433).     In  this  manner  the  peritoneum  of  the  broad  hga- 

FiG.  432 


¥  ir0 


-I'l'M'^i 


._,,,    , ,  _,        .J^3i^iigf^pi%       ..... 

Infiltration  within  the  base  of  a  cystadenoma  of  the  ovary. 

ment  and  pelvis  and  also  the  omentum  and  abdominal  peritoneum  may 
become  the  site  of  secondary  growths  and  at  the  same  time  an  abdominal 
ascites  may  develop  which  often  obscures  the  real  disease.  Sometimes 
metastases  through  the  blood  stream  may  take  place. 

Parovarian  Cystomas. — Cysts  of  the  parovarium  are  usually  thin 
walled,  glandless  tumors  which  seldom  reach  a  notable  size.  They 
are  developed  subperitoneally,  and  hence,  when  they  grow,  they  carry 
the  peritoneum  before  them.  They  possess,  therefore,  three  coats:  the 
internal  epithelial,  a  middle  fibrous,  and  externally  a  peritoneal  coat. 
This  is  sujfficient  to  characterize  them.  The  tube  and  ovary  are  carried 
on  their  surface  so    that   when  the  tumor    becomes  large  the  tube  is 


PLATE   VI 


Parovarian  Cyst  with   Follicle  Cyst  of  the  Ovary. 


CYST/C    riMORS  or    Till:   or. IKY  COi) 

strc-tcluil  to  a  i;ii-at  K'n^th,  hut  tlu  ()\.ii\  is  iiiuhaii^i-d  >  l^lati-  \'l). 
Because  ot  tin-  irlaii\c  inacti\it\  of  the  cpit  helium  ihcic  is  no  tLiulciicy 
to  in\;ulc-  tlu  smiouiulinn  tissue.  TlKse  tumors  arc  silclom  rense, 
probably  bicausi-  of  tluii  relative-  seciitor\'  iiiacti\it\  .  'I'ht-  Huid 
content  is  clear  ami  ot"  low  sincific  <iravify,  usuall\  from  1005  to  1019, 
and  contains  no  albumin,  but  inxa  has  bicn  (kinonstratcd  'Ilcil). 

Clinically  these  tumors  arc  scon  usually  in  younji;  women  and  are 
o\  slow  <2;rowth.  They  do  not  become  malif^nant,  but  their  pedicles 
may  become  twisted,  and  the  usual  symptoms  attending  that  accident 
as  descrdnd  tor  the  pseudomucmous  cystomas  may  ensue. 

Fig.  433 


..^^^.'^rr^r-y 


•y:^'. 


/.••■™^ 


'  ^':^ :j^'0'-   ' X'-^-l-  S^ 


Peritoneal  metastasis  in  c3'stadenoma  of  the  ovary. 

Frequently  about  the  tube  and  ovarian  C3'sts  tbe  size  of  an  orange 
are  found.  The^'  are  probably  retention  cysts  of  some  of  the  fetal 
structures  in  that  region,  but  their  exact  anatomical  relationship  has 
not  been  determined. 

Diagnosis.  -The  diagnosis  of  cystic  ovarian  tumors  presents  different 
problems  when   they  are  confined   to  the  pelvis  and  when   they  have 
escaped  to  the  abdominal  cavit^•. 
39 


610 


TUMORS  OF  THE  OVARY 


When  Confined  to  the  Pelvis.^Tumors  up  to  the  size  of  the  head  of 
the  newborn  child  may  remain  in  the  pelvis.  When  approximately 
of  this  size  they  displace  the  uterus  usually  anteriorly  and  to  the  oppo- 
site side  (Fig.  434).  Tumors  of  somewhat  smaller  size  occup}^  the 
space  in  Douglas'  pouch  to  the  side  and  behind  the  uterus,  while  the 
smallest  ones  occupy  the  normal  site  of  the  ovary.  Each  of  these  has 
the  common  features  of  smoothness,  freedom  from  attachment,  and 
mobility.  Large  cysts  which  just  fill  the  pelvis  may,  because  of  this 
fact,  be  but  slightly  movable,  but  there  is  no  point  of  fixation.  In  some 
instances   a   secondary   fixation    takes    place,   but    cysts   in  which    this 

Fig.  434 


\ 

% 

t^ 

3Ls      A 

% 

M 

SF 

A 

^m 

y^m 

y 

i^^w^ 

pp 

S'-^P^"" 

^0 

M 

\      % 

mk 

S^^flE^^— 

FT 

Hlr 

hB 

SPr  '' 

m 

^3^S 

p 

Ovarian  cyst  confined  to  the  pelvis,  pushing  the  uterus  forward  and  to  the  opposite 
side:  S.F.,  sigmoid  flexure;  P.P.,  bands  of  pseudoperitoneum;  F.T.,  Fallopian  tube; 
A,  tuboovarian  abscess;   U,  uterus;    B,  bladder. 


occurs  are  usually  secondary  to  inflammatory  trouble.  The  differ- 
ence between  the  cystic  and  sohd  tumors  can  usually  be  made  out  on 
bimanual  examination.  The  small  cysts  even  when  relatively  dense 
will  rarely  be  mistaken  for  solid  tumors,  because  the  latter,  when  small, 
are  usually  exceedingly  dense.  The  dermoids  are  usually  distinguished 
from  others  by  their  oblong  shape  and  their  disposition  to  lie  anterior 
to  the  uterus.  The  parovarian  cysts  are  less  tense  and  their  relation 
to  the  tube  is  distinctive. 

Differential  Diagnosis. — Tuboovarian  Abscess. — Chronic   salpingitis   is 
not  infrequently   associated   with   cystic   formation  within   the   ovary. 


crsTJc  TiMoRs  or  rill.  or. iky  on 

I  In-  tlunl  (.ontciits  iiki\  he  pus  oi  more  or  Kss  ckar  lluid,  cUptiulin^  iipcMi 
the  sta^i-  of  the  chsiasi-.  Ihc-  (.haiacteiistics  are  the  Hxit\'  of  the  tumor 
at  or  near  the  normal  situation  of  the  ovar)'  and  the  thickened  tube 
leading!;  from  the  tumor  to  the  uterus.  When  hir^e  these  may  fill  the 
entire  retro-uterine  space,  and  in  rhcm  Hxarioii  is  more  marked.  There 
are  usualh    orlur  t\iil(.iucs  of  a  jirecedrnji;  ]nl\ic  inHaniiiiation. 

Myomas.  When  situated  suhperitoneall)'  a  sohrarv  myoma  behind 
and  latiial  to  the  uterus  ma\'  cause  confusion.  I  nless  it  has  a  very 
lon^  anil  thin  indicle,  its  attachment  to  the  uterus  can  be  shown  b\'  its 
movement  when  traction  is  made  on  the  uterus  by  means  of  a  tenaculum. 
If  this  maneuver  fails,  other  evidence  on  the  part  of  the  uterus  or  a 
"fibroid  heart"  may  aid  in  framing  a  conclusion.  .Myomas  within 
the  hioad  ligament  are  easily  recognized  because  of  their  relation  to 
the  uterus  and  their  low  position. 

It  occasional!}"  happens  that  a  tumor  belonging  outside  the  pelvis, 
such  as  a  mesenteric  tumor,  a  wandering  spleen,  and  the  like,  ma\' 
become  lodged  within  it.  The  degree  of  mobility  is  sufficient  to  demon- 
strate their  distant  origin. 

Carcinoma. — Carcinomas  of  the  ovary  present  additional  difficulty  in 
diagnosis;  the}'  are  dense,  often  bilateral,  and  are  often  attended  b}' 
ascites.  Carcinomas  derived  from  papillar}-  cystomas  usualh'  become 
fixed  earl}',  and  the  nodulations  produced  b}'  the  papillar}'  projections 
can   often   be   made  out. 

Tumors  Outside  the  Pelvis. — When  ovarian  tumors  from  their  size 
come  to  occupy  the  general  abdominal  cavity,  thev  usuall}'  lie  in  the 
median  line.  Thev^  are  globular  and  the  outlines  are  usually  distinct; 
but  very  flaccid  tumors  mav^  have  no  definite  outline.  Often  the  larger 
tumors  possess  several  loculi  which  aid  matenall}-  in  their  diagnosis. 
The\'  are  usuall}'  mobile  unless  fixed  b}'  previous  adhesions.  The  pseudo- 
mucinous are  usuall}'  dense  while  the  parovarian  are  most  often  flaccid. 
Ovarian  tumors  that  have  become  too  large  to  occup}'  the  pelvis  usuall}' 
require  differentiation  from  a  single  condition — pregnane}'.  The  em- 
barrassing situations  to  which  errors  in  diagnosis  of  these  conditions 
have  led  make  the  matter  of  more  than  ordinary  importance.  The 
usual  signs  of  pregnane}'  are  lacking,  although  the  lips  of  the  cervix 
ma}'  in  consequence  of  congestion  be  somewhat  softened.  1  he  ovarian 
tumors  are  globular  or  lobulated  while  the  pregnant  uterus  is  pear- 
shaped,  with  the  broad  end  extending  to  the  costal  margin.  The  ovarian 
c}'st  varies  in  densit}  in  the  different  cases,  but  is  constant  for  a  given 
tumor,  while  the  pregnant  uterus  varies  in  densit}'  at  different  times 
and  ma}'  often  be  made  to  become  more  dense  b}'  manipulation.  In 
the  more  advanced  pregnancies,  fetal  heart  sounds  will  be  heard. 


612  TUMORS  OF  THE  OVARY 

Ascites. — Large  ovarian  cysts  when  ver}^  flaccid  may  show  no 
boundaries,  and  the  flanks  ma}^  be  dull  on  percussion  with  the  intestines 
apparently  floating  upon  the  summit.  The  change  in  fluid  level  by 
change  in  position  is  less  in  tumors  than  in  ascites.  In  many  instances 
an  incision  must  clear  up  the  doubt.  Often  finding  the  presence  or 
absence  of  a  cause  for  ascites,  particularly  liver  and  heart  disease,  may 
be  of  value;  but  with  large  tumors  the  liver  outlines  are  made  out  with 
difficulty  and  the  heart  may  suff"er  from  the  size  of  the  tumor. 

Other  Abdominal  Tumors. — Other  abdominal  tumors,  such  as  hydro- 
nephrosis and  cysts  of  the  omentum  or  mesentery,  may  be  confusing; 
the  direction  of  their  mobility  and  the  absence  of  any  pelvic  attach- 
ment should  give  some  aid  in  diff^erentiation. 

Treatment. — The  simple  retention  cysts  require  excision  only.  The 
remainder  of  the  ovary  ma}^  be  safely  preserved. 

Simple  proliferation  cysts  when  unilateral  are  most  simph^  managed 
by  the  removal  of  the  tube  and  ovary.  Should  both  ovaries  be  aff^ected, 
the  ovarian  tissue  on  one  side  should  be  located  and,  together  with  the 
blood  supply,  be  preserved.  When  the  ovary  is  preserved  as  a  thin 
disk  this  may  be  folded  upon  itself  and  the  edges  carefully  sutured. 
This  procedure  preserves  menstruation  and  can  be  safely  done,  since 
these  cysts  do  not  tend  to  undergo  malignant  change. 

The  pseudomucinous  and  the  parovarian  cysts  are  easily  removed 
after  ligation  of  their  pedicles.  When  the  cysts  are  no  larger  than  an 
adult  head  it  is  more  satisfactory  to  remove  them  intact.  The  very 
large  cysts  are  better  removed  by  draining  off"  some  of  the  cyst  contents 
so  that  the  cyst  wall  can  be  removed  through  a  small  incision.  The 
pedicle  is  best  treated  by  incising  the  peritoneum  about  it,  retracting 
and  ligating  the  vessels  separately.  The  cuff^  of  peritoneum  is  then  re- 
placed and  the  edges  inverted  with  fine  catgut.  This  method  is  more 
satisfactory  than  transfixing  and  ligating  en  masse  the  entire  pedicle. 

The  serous  C3'sts  have  been  classed  as  semimalignant,  a  fact  that 
must  be  kept  in  mind  when  planning  the  treatment.  The}'  should  be 
removed  intact  because  of  the  possibility  of  transplantation  metastasis, 
and  when  bilateral  both  ovaries  and  tubes  should  be  removed.  When 
a  cyst  has  ruptured  and  the  papillary  mass  lies  exposed,  care  should  be 
taken  in  the  removal  lest  some  of  the  mass  be  broken  off^  and  give  rise 
to  secondary  tumors.  Even  when  there  are  small  secondaiy  tumors 
upon  the  peritoneum  removal  is  still  permissible,  for  cases  have  been 
known  in  which  the  small  secondary'  tumors  have  disappeared  after 
removal  of  the  primary  tumor.  When  tumors  cause  great  distress  from 
their  size,  even  when  extensive  metastasis  renders  a  favorable  outcome 
hopeless,  the  removal  of  the  primary  tumor  may  give  relief  for  a  time. 


aoLiD  ri  MORS  or  rm:  or. iky 


(•)i:i 


SOLID    TUMORS    OF   THE    OVARY 

I  In-  solid  tumors  ot  tlu-o\;ir\  lomiiiisi-  rvtr\'  };r;iclatioii  lioiii  cKnsc 
HbroiiKis  to  tin  most  (.illuhir  s;in-om;is,  m  tin-  comitiri\t'-rissui-  ^roup; 
;nul  m  rlu-  tpitluliiil  tumors,  from  dense-  scirrhous  carcinomas  to  malig- 
nant serous  cystomas.  In  each  of  these  groups  it  is  often  ditticult  to 
determine  if  a  tumor  has  passed  the  benign  stage  and  often  the  clinical 
course  must  be  considered  before  an  approximate  opinion  can  be  offered. 

I  he  atypical  connective-tissue  rumors  are  so  closeh'  related  that  thev 
ma\    be  considered  together. 

Sarcomas.  Sarcomas  are  the  most  trecjuent  solid  tumor  ot  the  o\ar\' 
and  occur  heiiuenrly  in  yoiin^  persons. 

Fig.  435 


^ 


-j> 


\ 


Sarcoma  of  the  ovarv. 


Pathology. — Macroscopic  Appear.ance.— Macroscopically,  the^-  form 
round  or  ovoid  tumors  usualh'  without  marked  irregularities,  but  often 
with  small  nodules  projecting  slightly  beyond  the  general  surface  (Fig. 
435).  The  color  is  usually  pinkish  white,  but  often  distincth-  pink, 
especially  in  the  more  cellular  areas.  They  may  be  dense  if  the  fibrous 
element  predominates  or  very  soft,  even  semisolid,  in  the  more  cellular 
forms.  The}-  are  prone  to  undergo  degenerative  changes,  chiefl\-  m\xoid 
in  character.  The  degenerated  areas  may  liquefy  and  form  c\sts,  which 
may  be  still  further  complicated  by  the  occurrence  of  hemorrhage. 


614  TUMORS  OF  THE  OVARY 

Microscopic  Examination, — This  shows  every  cell  type.  The  denser 
tumors  are  made  up  largel}^  of  fibrous  tissue  with  a  few  spindle  cells 
with  nuclei  of  varying  size.  The  connective  tissue  is  often  indistinct 
because  of  myxomatous  degeneration.  Mixed-celled  sarcomas  are  some- 
times seen,  and  not  infrequently  small  round-celled  varieties,  in  which 
the  intercellular  connective  tissue  is  very  hard  to  demonstrate.  Vessels 
are  few  and  necrotic  degeneration  of  large  areas  is  not  uncommon. 

Clinical  Course. — The  clinical  course  is  as  varied  as  the  microscopic 
picture.  The  denser  varieties  are  relatively  benign,  but  the  very  cellular 
ones  are  excessively  malignant.  In  the  latter  variety  lung  metastasis 
may  be  the  first  evidence  of  the  disease.  Sarcomas  may  extend  to 
neighboring  organs  by  continuity,  involving  in  this  manner  particularly 
the  sigmoid  and  rectum.  Rarely  degeneration  and  suppuration  are 
serious  complications. 

Endotheliomas. — These  tumors  are  rare,  but  no  doubt  some  which 
were  formerly  regarded  as  carcinoma  or  combinations  of  carcinoma  and 
sarcoma  are  of  this  class.  Olshausen  saw  but  one  case  in  293  ovarian 
tumors.^  Most  of  the  cases  were  reported  before  endotheliomas  were 
generally  recognized.  In  my  own  cases,  one  in  ten  of  the  solid  tumors 
(fibromas  and  sarcomas)  have  been  endotheliomas.  There  were  twenty- 
one  instances  of  bilateral  tumors  in  Barrett's  series,  and  he  states  that 
in  a  number  of  instances  in  which  the  apparently  healthy  ovaiy  was 
allowed  to  remain  it  subsequently  becomes  involved.  Endotheliomas 
occur  most  frequently  between  the  ages  of  forty  and  fifty  years,  though 
they  are  not  infrequent  in  young  persons. 

Pathology. — Macroscopic  Appearance. — They  form  globular  tumors 
with  smooth  surface,  though  frequently  nodulations  are  present,  par- 
ticularly when  they  are  undergoing  rapid  development  (Plate  VII). 
They  are  pinkish  in  color  and  are  usually  moderately  dense.  They 
show  the  usual  tA^pes  of  degeneration,  and  frequentl}^  form  cysts.  Many 
of  them,  particularly  the  more  rapidly  growing  ones,  tend  to  undergo 
necrosis.  Degenerated  areas  in  the  more  slowl}^  growing  ones  some- 
times undergo  subsequent  calcareous  infiltration. 

Microscopic  Appearance. — Microscopically  they  show  the  usual 
picture  of  endothelioma,  the  lymphangiomatous  type  being  the  most 
frequent.  When  the  growth  is  rapid  the  structure  may  be  cellular  and 
the  periphery  must  be  searched  for  evidence  of  their  endothelial  nature. 
Even  in  areas  in  which  an  endothelial  origin  cannot  be  demonstrated 
the  large  cells  with  abundant  protoplasm  suggest  their  endothelial 
character.  These  cells  in  size  and  structure  resemble  those  of  cellular 
testicular  tumors.      Because  of  their  analogous  situation  and  course  the 

^Quoted  by  Barrett,  Surg.,  Gynec,  and  Obstet.,  1907,  iv,  549. 


PLATE   V 


Endoihelioma  of  the  Ovai-y. 


SOLID   TCMOKS  OF   Till.   Ol    IKY 


(il.') 


posMlMlitx  of  :i  iil;itit)n  to  ilu-  liKuip  of  mixed  Illinois  whuli  so  coiii- 
nioiiI\  imsriit  the  St  I  ml  nil'  ol  iiulotlulioiiias  imisr  ht-  rliou^lit  of; 
tlioiiiih  i\ul(iu(  IS  I.ukiiiu,  possil)|\  l)ic;iiisi-  i-;iil\'  runiois  on  accouiU 
of  tluii  sciliuUvl  sitiKitioii  1ki\c  not  hicii  pitsiiurd  for  i\:miin;irion. 

Clinical  Course.  ilu'  onsit  is  msuiioiis,  tin  tiiinoi  often  nor  hfiiiK 
siispecteil  until  it  assiiims  a  position  aho\i-  the  |Klvif  hum.  l*or  this 
reason  tin-  onset  is  often  said  to  he  aciiti .  I  lemorrhau;e  into  degenerated 
areas  may  tiiNt.'  the  saim  im|iiission.  h.xcn  with  hirj^e  tumors  tin-  men- 
struation ma\  not  he  distuihed,  hut  sometimes  amenorrhea  is  present. 
Ascites  sometimes  complicates,  hut  when  this  is  present  particular 
caution  IS  necessary  lest  a  carcinoma  he  mistaken  for  an  endothelioma. 
Metastasis  has  appannrly  occurred  in  \arious  regions,  according  to 
the  reported  cases,  rather  more  frequently  than  is  usual  in  this  variety 
of  tumor,  resemhling  in  this  regard  the  mixed  tumors  more  than  the 
typical  endotheliomas.  They  extend  to  the  surrounding  tissue,  par- 
ticularly to  the  rectum. 

Fig.  436 


^< 


y 


-.-^ 


Fibroma  ol  the  ovary. 


Fibroma. — Small  tumors  composed  of  fibrous  tissue  ma\'  occur  about 
a  corpus  luteum.  The}'  are  simply  an  overproduction  of  fibrous  tissue 
in  the  ordinary  retrogressive  changes  in  the  corpus  luteum  and  are 
without  clinical  significance.  The  ovary  is,  however,  sometimes  the 
seat  of  fibrous  tumors  which  may  reach  a  considerable  size,  even  to 
twenty  pounds  or  more. 

Pathology. — M.a.croscopic  Appearance.— The\'  usually  form  spheroidal 
masses  (Fig.  436),  the  larger  ones  projecting  into  the  abdominal  cavitw 


616  TUMORS  OF  THE  OVARY 

On  section,  they  present  a  glistening  appearance,  with  fibrous  bands 
in  the  whorled  arrangement  characteristic  of  fibromas.  In  some  tumors 
there  is  an  admixture  of  muscle  cells  (probably  derived  from  the  blood- 
vessels) which  gives  them  a  pink  color.  These  tumors  are  subject  to 
the  usual  degenerations;  notabl}^,  calcareous,  fatty,  and  myxomatous. 
Cyst  formation  may  result  from  these  degenerative  changes,  or,  as 
Pfannenstiel  points  out,  from  combination  with  cystadenomas  or  the 
dilatation  of  lymph  spaces. 

Microscopic  Appearance. — They  are  made  up  largel}^  of  loosely 
arranged  fibrous  tissue  with  a  small  number  of  small  spindle  cells  of 
uniform  size  with  long  narrow  nuclei.  It  is  this  uniform  size  that  per- 
mits a  differentiation  from  the  more  dense  varieties  of  sarcoma.  The 
fibromatous  nature  of  such  tumors  must  always  be  regarded  with  a 
degree  of  suspicion,  for  sarcomatous  areas  are  easily  overlooked.  The 
softer,  pinkish  areas  should  always  be  examined  for  evidence  of  mahg- 
nancy. 

Clinical  Course. — The  clinical  course  is  insidious.  The  small  varieties 
are  discovered  accidentally  in  the  course  of  pelvic  operations  for  other 
lesions.  The  small  tumors  which  develop  from  the  corpus  luteum  are 
more  closely  related  to  the  keloids  or  hyperplastic  scar  formations.  The 
larger  proliferative  tumors  are  more  closely  related  to  the  sarcomas, 
and  like  them  may  or  may  not  cause  disturbance  of  the  menstrual 
function.  They  may  cause  pressure  sj^mptoms  when  still  in  the  pelvis, 
but  often  their  presence  is  not  suspected  until,  because  of  their  size,  they 
rise  above  the  pelvic  brim. 

Diagnosis. — All  solid  tumors  of  the  ovary  present  the  same  physical 
signs.  They  occupy  the  site  of  the  ovary  until  too  large  to  be  accommo- 
dated, when  they  rise  into  the  abdomen.  Their  density  must  difi^er- 
entiate  them  from  ovarian  cysts,  and  their  freedom  from  attachment 
to  the  uterus  must  differentiate  them  from  myomas  of  that  organ.  The 
differentiation  of  the  solid  tumors  from  each  other  often  requires  a 
careful  microscopic  examination.  The  dense  fibromas  can  often  be 
recognized  by  inspection  and  palpation  at  the  time  of  operation.  When 
of  rapid  growth  malignancy  may  be  suspected,  and  when  attached  to 
neighboring  organs  their  malignant  character  is  obvious.  Differentia- 
tion between  sarcomas  and  endotheliomas  requires  the  leisure  of  the 
expert. 

Treatment. — The  removal  of  the  ovary  with  the  upper  portion  of  the 
broad  ligament  is  usually  required.  When  bilateral,  both  ovaries  must 
be  removed.  Even  when  but  one  ovary  is  affected,  if  there  is  strong 
evidence  of  malignancy  the  desirability  of  the  removal  of  the  opposite 
ovary  must  be  considered.  If  the  patient  is  near  the  menopause  the 
problem  is  a  simple  one;  but  if  the  patient  is  young  the  sound  ovary 


SOLID   TCMORS  Ol'   Till:  fJl.lkV 


C.l 


should  In-  allow  111  to  n  main,  foi  in  most  nistances  the  second  ovary 
niiiains  htc.  In  this  cast-,  howt-Mi,  tlu  patient  should  remain  under 
the  ohsirvation  ot  tlu-  surgeon.  W  luii  arraciu-d  to  a  nl•l^hho^n1^  oruan 
a  resection  of  that  or^an  must  hv  uiuKi  takiii. 

Carcinoma.  Carcinomas  ot  the  ovai\'  ate  less  Ircujuent  tiian  c\sts, 
but  arc  tlu  most  t'r«.(iuent  malij2;nant  timior.  A.  Martin,'  in  236  ovarian 
tumors,  touiui  42  malignant,  ot  which  32  wc-re  carcinomatous.  1  hey 
occur  usualU  on  tin-  ri^iit  sick,  hur  arc  ottcii  bilateral.  The)'  result 
most  tVeciuently  from  mali<inant  ti  ansformation  of  papillar\-  c\-stadeno- 
mas,  less  often  they  develop  primaiil\  in  the  interior  of  the  ovary,  and 
still  less  often  the\'  develoji  fiom  pseudomucinous  cystadenomas  and 
dermoids.  Those  derived  from  cysts  are  most  common  in  middle  life; 
while  the  primary  tumors  usuall\'  occur  later,  often  alter  the  meno- 
pause. As  a  notable  exception  to  the  last  statement,  are  those  said 
to  occur  in  \()un<!;  women  and  even  in  children;  but  the  correctness 
of  the  diat^nosis  of  man\-  of  these  tumors  must  be  (juestioned. 


ic.  437 


C 


aicinoma 


of  the 


Primary  Carcinomas. — Walde^er-  believes  that  the\"  develop  from  the 
germinal  epithelium,  but  StefFeck,-^  while  admitting  that  this  may  be 
the  point  of  origin  in  some  instances,  believes  that  usually  the  follicular 
epithelium  is  the  source  of  the  tumor. 

Pathology. — Macroscopic  Appearance. — Arising  within  the  capsule  of 
the  ovar}^  they  retain,  in  a  general  way,  the  external  form  of  the  organ 
(Fig.   437).      Irregularities   in   the   surface   appear  particularly   as   they 


^  Kranktieiten  der  Eierstocke  und  Xebeneierstocke,  Georgi,  Leipzig,  1899. 

-  Volkmann's  klin.  Vortr.,  No.  33. 

'Ztschr.  f.  Geburtsh.  u.  Gynak.,  1894,  xxviii,  147. 


618  TUMORS  OF  THE  OVARY 

become  larger  and  grow  more  rapidly.  They  are  usually  very  dense 
in  consistency,  but  may  become  softer  when  degenerative  processes 
set  in.  When  these  tumors  develop  rapidly  the  capsule  may  be  per- 
forated by  direct  extension.  The  color  is  characteristically  yellow, 
the  nodules  particularly  standing  out  a  distinct  yellow  in  contrast  to 
the  whiter  connective  tissue  in  the  depressions.  On  cross-section, 
the  striking  coloration  is  prominent.  The  fibrous  tissue  forms  a  net- 
work surrounding  the  yellow  areas,  and  often  cysts  filled  with  a  clear 
fluid  are  found.  Hemorrhage  into  these  cysts  or  into  a  degenerated 
area  in  the  centre  of  the  yellow  masses  may  take  on  various  hues  and 
much  complicate  the  picture.  In  the  more  rapidly  growing  type,  par- 
ticularly those  of  young  persons,  the  color  is  more  homogeneous  and 
of  a  pinkish-white  color.     They  are  often  bilateral. 

Microscopic  Appearance. — The  usual  appearance  is  that  of  a  simple 
carcinoma;  gland-like  spaces  are  commonly  seen.  Degenerative  areas 
are  frequent  and  myxomatous  degeneration  of  connective  tissue  is 
sometimes  observed.  The  cell  forms  are  cuboidal  and  usually  deep- 
staining,  but  in  some  specimens  large  cells  with  clear  cytoplasm  are 
seen  within  the  cell  columns.  These  resemble  primordial  ova,  and 
Emanual^  so  regarded  them,  while  Gebhard^  beUeves  they  are  degener- 
ated carcinomatous  cells.  Similar  cells  are  seen  in  the  exfoliated  epithe- 
lium of  cystomas.  In  some  tumors  the  cells  are  not  arranged  in  definite 
alveoH;  often  connective  tissue  surrounds  each  individual  cell.  Often 
they  suggest  a  combination  of  sarcoma  and  carcinoma,  and  may  be 
distinguished  with  difficulty  from  endotheliomas.  Grouping  of  the 
cells  in  glandular  fashion,  with  or  without  a  small  lumen  in  the  centre, 
suggests  their  epithelial  nature. 

Secondary  Carcinomas. — These  tumors  are  most  often  developed  from 
the  serous  cystomas.  According  to  PfannenstieP  one-half  of  these 
tumors  are  malignant.  The  pseudomyxomas  become  malignant  less 
often  and  the  dermoids  still  less  frequently. 

Pathology. — Macroscopic  Appearance. — In  the  early  cases  these 
tumors  cannot  be  distinguished  from  cystomas.  The  early  macro- 
scopic changes  observed  are  the  thickening  of  the  papillae,  often  in  the 
base  of  the  tumor,  and  sometimes  invasion  of  the  broad  ligament.  In 
the  more  advanced  cases,  when  the  broad  ligament  is  extensively  infil- 
trated, it  may  be  impossible  to  distinguish  this  type  from  the  primary 
variety,  for  in  these  too  the  nodules  are  of  a  yellowish  color;  but 
usually  there  is  some  portion  that  presents  evidence  of  its  cystic  origin 

^  Ztschr.  f.  Geburtsh.  u.  Gynak.,  1893,  xxvii,  62. 

2  Path.  Anat.  d.  weiblichen  Sexualorgane,  Hirzel,  Leipzig,  1899. 

^  Arch.  f.  Gynak.,  1894,  xlviii,  507. 


SOLID   Tl'MORS  or   THE  Ol    IRY 


(ill) 


(Fi^.  4^8),  or  jHihaps  tlu  ojiposite  ovar\'  may^  present  a  tumor  more 
elementary'  in  structure  which  clears  up  the  situation.  (Jn  section, 
these  tumors  present  \  ellowish  areas  surrounded  b)  c(jnnective  tissue. 
In  these,  as  in  the  primary  type,  then-  ma\  he  cystic  spaces  filled  with 
clear  fluid  and  dei;enerated  areas,  often  with  secondarv'  hemorrhaj^e. 

Fk;.  438 


Carcinoma  of  the  ovar}'  secondar\-  to  a  serous  cystoma. 

When  pseudomucinous  cystomas  become  malignant  the  changes 
occur  in  the  cyst  wall.  Areas,  usually  about  the  base,  become  thickened 
and  more  dense.  The  infiltration  becomes  more  and  more  widespread, 
often  involving  the  broad  ligament  extensively,  while  the  remainder 
of  the  tumor  shows  no  change. 

Metastatic  Carcinoma. — The  relative  frequency  of  metastatic  ovarian 
carcinomas  has  been  variously  estimated.  In  79  cases  in  which  tumors 
of  the  digestive  tract  and  ovarian  tumors  co-e.\isted,  Schlagenhaufer^ 
believed  that  in  every  instance  the  ovarian  tumors  were  secondary. 
Glockner-  believes  that  all  bilateral  ovarian  carcinomas  are  secondary. 
This  fact  explains  the  clinical  observation  of  Martin  that  these  tumors 

^  Monatsschr.  f.  G\nak.,  1902,  xv,  485. 
^  Arch.  f.  G3nak.,  1904,  Ix.xii,  410. 


620 


TUMORS  OF  THE  OVARY 


when  removed  are  followed  in  a  short  time  by  the  death  of  the  patient 
from  exhaustion.  Belonging  to  this  class  of  tumors  are  those  described 
by  Kruckenburg^  under  the  name  fibrosarcoma  ovarii  multicellulare 
(carcinomatodes).  These  tumors  are  characterized  by  large  cells 
with  abundant  protoplasm  with  the  peripheral  location  of  the  nucleus, 
together  with  an  abundant  stroma.  Ulesko-StroganofF^  has  recently 
shown  that  these  tumors  are  carcinomas  and  probably  always  secondary 
to  carcinoma  of  the  stomach.  The  disposition  of  secondary  tumors 
from  the  gastro-intestinal  tract  to  colloid  degeneration  is  sufficient 
explanation  for  the  occurrence  of  the  "signet-ring  cells"  which 
Kruckenburg  regarded  as  characteristic.  Plate  VIII  represents  a 
tumor  of  this  class. 

Fig.  439 


Invasion  of  the  cyst  wall  in  serous  cystadenoma  of  the  ovary. 

Microscopic  Appearance. — The  first  changes  in  the  papillary  type 
is  the  piling  up  of  the  epithelium.  In  this  manner  large  masses  may 
be  formed  which  lead  to  invasion  of  the  surrounding  tissue  by  contact 
metastasis  and  by  infiltration  before  the  base  of  the  tumor  is  invaded. 


1  Arch.  f.  Gyniik.,  1896,  1,  287. 

^  Zentralbl.  f.  Gynak.,  191 1,  xxxv,  1049. 


0 


SOI. 1 1)  TiMOMs  or  Tin:  or./kv 


(-.21 


Soomr  or  hitti  tlu  hioiul  li;;amint  lucoims  inHltratcd.  in  rhe  pseudo- 
nuicinous  t\  |^i-  rlu-  larlicsr  changes  art-  in  tlu-  pihn^  up  ot  rlu-  sniallt-r 
c\  sts  in  the  wall  of  tin-  rumor  (  M^.  439),  usuallv'  at  the  base.  The 
border-line  is  diHicult  to  place,  for  in  many  tumors  clinicall\'  benign 
the  arrangement  and  character  of  the  cells  strongly  suggest  malignancy. 
In  the  absence  of  any  invasion  and  reactive  proliferation  on  the  part 
of  the  connccti\c  tissue  the  diagnosis  of  carcinoma  must  be  made  with 
caution. 

Clinical  Course. — The  tendenc)'  of  each  of  these  types  to  invade  the 
surrounding  tissue  has  been  sufficiently  dwelt  upon.  Extension  is  usually 
by  direct  continuity,  most  frequently  to  the  broad  ligament,  the  pelvic 
peritoneum,  the  tubes,  and  the  uterus.  In  some  instances  the  secondary 
nodules  upon   the  peritoneum  (Fig.  440J  when  first  transplanted  have 

Fig.  440 


Omental  metastases  in  papillary  cystoma  of  the  ovary 


the  structure  of  a  benign  cyst,  and  in  this  new  situation  ma}'  undergo 
malignant  transformation,  thus  presenting  evidence  of  a  vicious  heredity. 
\\  ith  the  invasion  of  the  surrounding  peritoneum  ascites  develops  to 
such  a  degree  as  often  to  overshadow  the  real  disease.  The  presence 
of  an  unexplained  ascites  should  alwa\'s  excite  suspicion  of  an  ovarian 
carcinoma.  With  the  spread  of  the  disease  surrounding  structures 
suffer.     The  veins  of  the  pelvis  particularl\'  are  compressed  or  invaded, 


622  TUMORS  OF  THE  OVARY 

and  dilatation  of  the  superficial  veins  of  the  lower  abdomen  and  edema 
of  the  legs  ensue.     The  ureters,  rectum,  and  bladder  are  often  affected. 

Metastasis  is  not  so  common  as  extension  by  continuity.  The  bilateral 
occurrence  of  these  tumors  is  explained  as  metastasis  by  some  writers; 
but  the  fact  that  both  arise  at  about  the  same  time  and  that  metastases 
in  other  regions  are  not  common  suggests  that  the  bilateral  origin  is 
primary.  Metastasis  takes  place  most  often  in  the  lungs  and  liver, 
and  may  occur  earh^  before  an  ovarian  tumor  is  suspected;  even  if  one 
is  discovered,  the  malignant  area  may  be  demonstrated  with  difficulty. 
The  bones,  the  retromesenteric,  and  even  the  inguinal  glands  may  be 
the  site  of  metastasis. 

Diagnosis. — The  discovery  of  a  dense  tumor  of  the  ovary  raises  the 
question  of  carcinoma.  The  fibromas  may  be  dense,  but  they  lack  the 
nodulations  usually  present  in  carcinoma;  in  addition  fibromas  when 
first  discovered  are  usually  larger  than  carcinomas  when  they  begin 
to  make  trouble.  If  the  tumor  is  bilateral,  it  speaks  strongly  for  carci- 
noma. The  reported  cases  of  bilateral  endothelioma  in  women  in  middle 
life  complicated  with  ascites  too  often  lack  convincing  evidence  of  the 
correctness  of  the  diagnosis,  and  the  surgeon  will  do  well  when  he  meets 
this  combination  to  make  a  clinical  diagnosis  of  carcinoma.  Ovarian 
carcinomas  which  develop  from  cysts  present  two  problems.  In  the 
first  place  it  must  be  determined  whether  a  given  tumor  is  primarily 
cystic  when  it  gives  evidence  of  malignancy;  when  a  cyst  is  discovered, 
has  it  undergone  malignancy .? 

The  first  problem  comprises  the  clinical  nicety  of  determining  the 
type  of  carcinomas,  while  the  latter  involves  the  important  question 
of  therapeusis.  When  a  cyst  is  discovered,  evidence  of  malignancy 
may  be  discovered  m  the  broad  ligament.  The  presence  of  ascites 
speaks  for  malignancy,  and  the  presence  of  dilated  veins  over  the  lower 
abdomen  and  the  upper  portion  of  the  thighs  speaks  not  only  for  malig- 
nancy, but  also  for  such  a  degree  of  invasion  as  makes  the  tumor  in- 
operable. Hydrothorax  even  in  the  presence  of  ascites  should  excite 
a  strong  suspicion  of  pulmonar}^  metastases.  The  common  picture  of 
ovarian  carcinoma  when  seen  in  practice  is  so  striking  that  it  can  scarcely 
be  overlooked.  A  woman  at  or  past  middle  fife,  with  gradually  increas- 
ing ascites  without  demonstrable  cause,  with  gradual  emaciation,  and 
a  pinched,  anxious  expression,  requires  but  the  palpation  of  a  tumor 
filling  the  pelvis  and  projecting  above  the  pelvic  brim  in  small,  dense, 
nodular  masses  to  complete  the  diagnosis. 

Treatment. — Cystic  tumors  of  the  ovary  if  removed  early  would  lessen 
the  number  of  ovarian  carcinomas  to  be  treated.  When  definite  malig- 
nancy has  developed,  the  entire  mass  may  yet  be  removable.  The 
primary  carcinomas  often   remain   free  from   adhesions   and   are  easily 


SOLID  ri  MORS  or  rill:  or. IKY 


\\Z\ 


rt.iiit)\  til,  iiMKilh  ,  li()\\i\  II ,  ro  l>r  l()ll()\Mil  1)\  ic-cmiriui-.  M;irnii,' 
who  InliiMs  liihitii  ;il  tiimois  iiuluMif  iiutastasis,  clcclarc-s  that  all 
bilartial  caiciiiDinas  an  iiu)|HraMr.  When  the  tumor  has  spread  to 
the  surrouiulin^  tissiu-  atti-mprs  at  operation  are  useless.  1  he  opera- 
tive results  are  not  brilliant.  Only  three  of  Martin's  cases  lived  more 
than    three   \eais. 

Dermoids  of  the  Ovary.  Olshausen-  estimates  that  dermoids  make 
up  4  per  cent,  ot  ()\arian  tumors.  The)'  are  usuall)'  undateral  and  (jccur 
more  often  on  the  li^ht  side,  Inir  they 

ma\-   hv  hilareral.       riu\    have   Inen  I'k;.  442 

foimd  in  situations  other  than  the 
o\ar\'  and  ha\'e  been  ascribed  to  an 
accessor\-  ovar\-.  ,.>    -  ;•>;•.-. .-.Vr- 


su 


In    contrast    to    dermoids    of    the       ^'!''^:r,r-:;;\v-.' 
rface  of  the  bod\',   these  are  now       '\  ■^^;^=i^iv■'i-•"""■-^V:- 


believed  to  be  ovigenic  in  origin. 
Walde3'er^  was  the  first  to  suggest 
this  origin,  but  it  remained  for 
Wilms^  to  develop  the  evidence. 


•;,%:; 

V-  ^•r,.^v 

";  ''':':'^-' 

/^/ 

i.^vy'.'./  ■  -'j 

W- 

-/■v^,"-'^i 

^<r,.'J^e- 


Fig.  441 


;;?V..:'^ 


,  :.--"'.-'.-."v-^'f'.-'''./iV.l"-' ■  ■•!■■.   ••■'.■.•' V/v,?*  ■  ■  '.-■  ■  '  ■.  ■  ';•'". 


■Sk-^^>:':^ 


''^^"*^W- 


^iO^' 


Dermoid  of  the  ovarv. 


Dermoid  ot  the  ovary. 


'  Die  krankheiten  der  Eierstocke,  Georgi,  Leipzig,  1899. 
-  Krankheiten  der  Ovarien,  Enke,  Stuttgart,  1885. 
'Arch.  f.  Gynak.,  1872,  i,  305. 
^  Deutsch.  Arch.  f.  klin.  Med.,  1896,  Iv,  289. 


624  TUMORS  OF  THE  OVARY 

Pathology. — Macroscopic  Appearance. — They  are  usually  globular  or 
ovoid  tumors,  with  smooth  surface  and  well-defined  pedicle  (Fig.  441). 
They  are  usually  the  size  of  a  fist,  but  sometimes  larger.  When  observed 
in  the  living  they  are  soft  and  fluctuating,  but  when  allowed  to  cool 
they  become  semisolid.  The  change  in  consistency  is  due  to  the  solidifi- 
cation of  the  contained  fat  when  the  temperature  is  reduced.  If  cut 
while  the  tumor  is  still  warm,  the  fatty  contents  escape;  but  if  cool, 
the  interior  is  filled  with  a  granular  plastic  fat  containing  within  it 
strands  of  hair  and  often  teeth.  These  structures  find  their  origin  at 
one  portion  of  the  tumor,  while  the  remainder  of  the  cyst  wall  is  thin 
and  smooth. 

Solid  Tumors  {Teratomas)  are  sometimes  observed  in  the  ovary. 
They  are  made  up  of  the  same  structures  as  the  dermoids,  but  the  pres- 
ence of  large  numbers  of  embryonal  cells  makes  them  prone  to  malignant 
development. 

Microscopic  Examination. — The  most  constant  finding  is  the  struc- 
tures common  to  the  skin,  hair  follicles,  and  sudoriferous  and  sebaceous 
glands  (Fig.  442).  Teeth,  if  present,  imitate  the  structure  of  the  normal 
organs.  Smooth  muscle  fibers  are  often  observed  and  rarely  striated 
fibers  have  been  found.  Tissues  representative  of  the  intestinal  and 
respiratory  tract  have  been  described.^ 

Clinical  Course. — Ovarian  dermoids  are  usually  slow  of  growth,  though 
Wilms  states  they  grow  rapidly.  They  cause  Httle  disturbance  unless, 
as  often  happens,  the  pedicle  becomes  twisted,  when  suppuration  may 
cause  the  gravest  consequences. 

Diagnosis. — Their  smooth  elastic  surface  and  free  mobility  are  sugges- 
tive, and  their  disposition  to  be  located  in  front  of  the  uterus  is  said  to 
be  characteristic. 

Treatment. — Removal  is  usually  easily  accompHshed.  If  twisting  of 
the  pedicle  has  been  followed  by  suppuration,  drainage  may  be  required. 

TUMORS   OF   THE   FALLOPIAN   TUBES 

Tumors  primarily  in  the  tubes  are,  on  the  whole,  rare,  though  many 
types  have  been  observed.  Sanger  and  Barth^  report  a  number  of 
papillary  carcinomas,  and  four  cases  of  bilateral  occurrence  have  been 
noted.  They  expand  the  walls  of  the  tubes  and  may  later  infiltrate 
and  perforate  them.  Not  infrequently,  carcinoma  of  the  tube  follows 
that  of  the  uterus,  and  syncj^tioma  malignum  has  also  been  observed 
here.     Sarcomas  have  occurred  but  five  times,  the  small  round-celled 

^  Virchow's  Arch.  f.  path.  Anat.,  1887,  cvii,  515. 

^  Martin's  Krankheiten  der  Eileiter,  Georgi,  Leipzig,  1895,  p.  251. 


TUMORS  or  Tin:  i.ii.i.ori.i\  rinrs 


025 


type    piiclomiiKitiiit;.       I  h(\     ;m-    iimi;iII\     sitiKirtd    in    tlu-    siil)imif()sa.* 
SriKill   iKululis  ol    tiluoiis   (isMu-   Willi   iiiici  inin^lcd   cpitlulKil   tissue,   the 

l-K;.  44? 


Salpingitis  nodosa. 

so-called  salpingitis  nodosa,  form  the  most  ti"e(|uent  tumor  of  the  tube. 
The}'  form  nodules,  hazelnut  m  size,  situated  usually  near  the  horn  of 
the  uterus   (Fig.  443). 

^  See  also  v.  Kahlden,  Beitr.  z.  path.  Anat.  u.  z.  allg.  Path.,  1897,  xxi,  275. 


40 


CHAPTER    XLI 

TUMORS  OF  THE  VULVA  AND  VAGINA 

TUMORS  OF  THE  VULVA 

Cystic  Tumors. — C3^sts  of  the  Bartholin  glands  are  common.  They 
result  usually  from  a  preceding  inflammatory,  usually  gonorrheal,  affec- 
tion. They  are  generally  the  size  of  a  walnut,  but  occasionally  much 
larger.  They  occupy  the  site  of  the  gland,  and  the  absence  of  tender- 
ness distinguishes  them  from  inflammatory  affections.  They  may  be  mis- 
taken for  fibromas  or  adenomas.  Incision  or  puncture  ma}'  be  required 
to  differentiate.     Excision  is  the  preferred  method  of  treatment. 

Cysts  of  the  Hymen. — Sometimes  at  the  edge  of  the  hymen  small 
cysts  are  found,  generally  in  children  or  in  virgins.  Their  import  is 
uncertain.  Some  of  them  at  least  seem  to  be  retention  cysts  or  rem- 
nants of  Gartner's  ducts. 

Hydrocele  of  the  Round  Ligament. — The  canal  of  Nuck  ma}^  become 
distended  with  fluid  and  form  a  cj^st.  The  situation  and  continuation 
into  the  inguinal  canal  is  sufficiently  characteristic.  They  ma}^  be 
confused,  when  encapsulated,  with  solid  tumors  of  the  round  ligament. 

Solid  Tumors. — Fibroma  and  Fibromyoma. — Fibromas  of  the  vulva  are 
rare  tumors  (Fig.  444).  They  may  occur  anywhere  about  the  vulva, 
but  are  most  frequently  found  at  the  termination  of  the  round  ligament. 
They  are  circumscribed  tumors,  slow  of  growth,  and  usually  relatively 
soft.  On  section,  they  present  the  white  glistening  surface  common  to 
fibromas. 

Elephantiasis. — This  condition  is  more  common  than  true  fibromas; 
It  is  a  more  or  less  circumscribed  proliferation  of  the  subcutaneous 
fibrous  tissue,  which  frequently  affects  the  entire  labium.  It  forms  soft 
pendulous  fibrous  masses,  sometimes  pedunculated,  covered  by  the 
skin,  which  is  often  thickened  and  corrugated.  It  is  usually  due  to 
an  occlusion  of  the  inguinal  glands  from  some  preexisting  venereal 
infection. 

Lipoma. — Fatty  tumors  of  the  labia  majora  are  occasionally  observed. 
They  are  soft  and  circumscribed  and  have  a  semifluctuating  consistency 
which  resembles  closely  the  cysts  in  this  region. 

Adenomas. — The  Bartholin  glands  may  be  the  seat  of  epithelial  pro- 
liferation which  forms  hard,  painless,  circumscribed  nodules.     The  site 


r  I  MORS  or  Till:  1 1  I. II 


(-.27 


usiiall\  i;i\is  ;i  (.Iiu-  to  tluii  tKitiiu.  (  )ii  stirion,  tl.t-  |niiuiilorm  sinlace 
IS  suthciiiif  to  ililft  !i  HI  lair  il)(  111  lioin  cliioiiir  tilnoiis  iiuliiiatioii  of  the 
j^laiul. 

I  lu-  sil>aiH-ou.s  L:,laiuls  al>oiii  ilu-  \ul\a,  Iiasci  ahdonu-n,  or  thi^h  are 
hiHiiuntl\  rlu'  site-  ot  aiti\i-  prolilii  at  ion.  'I"lu\-  toiiii  lu-inisplu'iical 
proKctions   upon    tin-  surtatr  ol    tin-   skin    il"i<i,.  4-| ;  u  painK-ss  and   slow 

Fk;.  444 


Pedunculated  fibroma  of  the  vulva 


growing.  On  section,  they  give  the  arrangement  of  a  c\stopapilloma, 
which  is  usually  easily  made  out  microscopically.  Because  of  their 
nipple-like  form  and  glandular  structure  these  are  often,  I  believe 
erroneously,  regarded  as  accessory-  mammary  glands. 

Sarcoma. — Malignant  fibrous  tumors  of  the  vulva  are  rarities.     Most 
frequently   the}-  go  out  from   the   termination   of  the   round   ligament. 


628 


TUMORS  OF  THE  VULVA  AND  VAGINA 
Fig.  445 


;w^a^:;5^3E;i 


Adenoma  of  skin  of  perineum. 


Fig.  446 


Lymphangioma  of  the  perineum. 


riMoRs  or  riii:  ni.r.i 


(;2!> 


1  licy  arc  tor  a  tunc  slowly  j;roN\iii^,  since  thc\  arc  s|)iiullc-cclKcl  m 
type. 

Cavernous  Tumors.  Lymphangioma.  Lymphangiomas  are  sometimes 
obsciNctl  about  tlic  \iil\a,  hut  they  arc  chstinct  rarities  (Fig.  446). 

Hemangiomas.  The  vessels  of  the  vuKa  are  trecjuently  dilated,  form- 
uiii;  \aricosities,  hut  piolili  ratuiii,  \ascuhii  rumors  an-  \cr\'  rare.  Super- 
Hcial  anjiicctatic  tumors  arc  ohscrx'cd,  hut  tlu\  diHci"  ui  no  way  from 
sum  la  r  tumors  elsewhere. 

Fi<;.  447 


Carcinoma  of  the  vulva. 


Ulcers  of  the  Vulva. — Tuberculosis. — Tuberculous  ulcers  of  the  vulva 
are  irregular  and  ragged,  with  soft  borders.  The\'  are  usualh-  found  in 
3oung,  poorly  nourished  girls. 

Carcinoma. — Occasionally  epitheliomas  occur  about  the  vulva,  par- 
ticularly on  the  internal  surface  (Fig.  447),  and  in  many  cases  invade 


630 


TUMORS  OF  THE  VULVA  AND   VAGINA 


the  urethra.  Carcinomatous  extension  from  neighboring  organs  is 
sometimes  observed.  The  usual  characters  of  carcinoma,  dense  infil- 
trated border  and  cancer  plugs,  may  be  noted  here  as  elsewhere. 

Esthiomene  (Rodent  Ulcer  of  the  Vulva). — This  is  a  disease  of  the 
vulva  characterized  b}^  ulceration  and  tumor  formation.  It  is  eminently 
chronic  m  its  course  and  of  unknown  etiology. 

Etiology. — The  frequent  association  of  the  disease  with  prostitution 
leads  to  the  assumption  that  it  is  syphilitic  in  origin.  The  character  of 
the  disease,  as  the  name  indicates,  most  resembles  lupus,  and  a  number 

Fig.  448 


Esthk 


of  authors  have  believed  it  to  be  of  tubercular  origin.  Some  cases  have 
been  reported  in  which  tuberculosis  was  said  to  be  present,  but  definite 
proof  of  such  statements  are  lacking.  The  histological  resemblance 
to  elephantiasis  has  led  to  the  supposition  that  previous  purulent 
inflammations  in  the  inguinal  lymphatics  were  responsible  for  the 
disease;  but  most  of  the  cases  reported  were  not  preceded  by  such 
processes. 

Pathology. — In  some  cases  the  ulceration  predominates  (Fig.  448). 
The  outline  is  usuall}^  serpiginous  and  the  edges  are  usually  slightly 
undermined,  and  even  in   this  type   infiltrated  and  elevated.     In  some 


TiMoks  or  rill,  iri.i  ,1 


(iiil 


cases  nodulis  ot  diiisc-  white-  rissiu-  suiiouml  the  uKci  i  \\\i,.  44*;)  <>r  nia\' 
In- imsiiit  \s  It  hour  iikci  ;i(  ion.  I  su;ill\  horh  lesions  arc- coiiibimcl.  I  he 
nodules  arc  usuall\  m  tin-  forward  pair  ot  the-  vulva,  while  the  ulcers 
are  coninionl\  about  tin-  posterior  commissure.  The  ulceration  may 
e.xtend  sonu-  ihstance  into  the  \a<iina  or  into  the  nctum.  Kither  of 
these    canals    nia\     hi-    contracted    h\     the    accompanyinji;    hyperplastic 

I-k;.  449 


Esthi 


processes.  1  he  ulceration  may  e.xtend  so  deeply  as  to  form  fistulous 
openmgs  from  the  penneum  into  the  vagina  or  tectum,  or  both.  Esthi- 
omene  is  usually  confined  to  the  vulvar  region,  but  it  may  extend  over 
the  entire  penneum,  over  the  mons  veneris,  and  even  into  the  groin. 
Healing  may  take  place  in  one  part  with  the  production  of  extensive 
scars,  while  the  process  remains  active  in  other  regions. 

Histologically,  esthiomene  resembles  elephantiasis.     Bundles  of  fibrous 


632 


TUMORS  OF  THE   VULVA  AND  VAGINA 


tissue  with  groups  of  cells  make  up  the  bulk  of  the  tissue  (Fig.  450), 
and  there  are  occasional  softer  edematous  areas.  Vessels  are  not  numer- 
ous and  are  often  surrounded  by  masses  of  cells.  The  epithelium 
is  somewhat  thickened,  particularly  about  the  edge  of  the  ulceration 
(Fig.  451),  which  has  led  to  the  diagnosis  epithelioma. 

Course. — The  course  of  the  disease  is  chronic.  Many  years  usually 
have  elapsed  before  the  patient  seeks  treatment.  The  general  health  is 
unaflPected,  and  the  patient  seeks  medical  aid  usually  from  social  reasons, 


Fig.  450 


'^', 


'*'«^l  ■ 


^k 

- » < . 

' '     '  _   "  *  0% 

osfc  ■> 

00  -  -*  _^  _ 

av  0    e 

.pi'i, 

-°  '  ^\°  '  l  1 

-r  '.'^i. 


?# 


Esthiomene,  showing  epithelium,  round  cellsj  and  proUferated  connective  tissue. 


rather  than  from  any  suffering.     In  the  more  severe  forms  of  the  disease, 
cicatricial  contraction  may  lead  to  stricture  of  the  vagina  or  rectum. 

Diagnosis. — Esthiomene  resembles  elephantiasis  in  its  clinical  course 
as  well  as  in  its  history.  In  the  latter  disease  there  is  no  ulceration, 
and  the  tumors  are  confined  to  one  or  more  portions  of  the  vulva.    The 


TUMORS  01    Till:    I  I  LI  A  {\\\\\ 

resemblance  to  lupus  is  hut  supeiHcial.  Tlu-  hordt  is  of  lupus  are  softer, 
more  unckrmirutl,  aiui  there  is  more-  pain  than  in  esthiomene.  ^'he  base 
of  the  lupous  ulcer  is  softer  and  more  tender.  I'he  healing  lupous  ulcer 
is  not  accompanied  b\'  the  dense  masses  of  Hbrous  tissue.  'Ihe  patient 
affected  by  esthiomene  is  usually  in  the  midst  of  se.xual  life  and  other- 
wise robust,  in  marked  contrast  to  the  patient  who  has  lupous  ulcera- 
tions  of    the   genital    region.      Carcinoma    is    marked    by    an    ulcerative 

Fig.  451 


o  a  o    t?  •^ 


,,  T3  o 


^<^^>.c -.-•...:       ,.  ^^ ^^^^•'t:^ a-^^:,'%-r,^0  0--^_.:,^^<'^.-oZ'ip 


Esthiomene,  showing  h3perplastic  epithelium,  round  cells,  h>pertrophied  connective 

tissue. 

process  which  begins  at  one  point  and  e.xtends  from  this  as  a  centre. 
The  floor  of  the  ulcer  feels  dense  and  the  border  often  shows  the  cancer 
plugs.     A  microscopic  section  will  seldom  be  required  for  diagnosis. 

Prognosis. — The  disease  is  usually  incurable.  The  process  while  it 
heals  at  one  place  is  likel}'  to  extend  at  another.  Cure  brought  about 
bv  operative  means  or  by  the  use  of  the  cautery  is  only  temporarv. 


634  TUMORS  OF  THE  VULVA  AND  VAGINA 

Treatment. — Syphilitic  remedies  are  without  influence.  In  the 
lighter  cases  cleanliness  with  a  judicious  use  of  caustics  or  the  cautery" 
has  been  followed  by  healing.  Landau  employed  lactic  acid  with  suc- 
cess. The  nodules  may  be  excised.  If  the  urethra  has  been  destroyed 
or  stricture  has  formed,  plastic  operations  may  be  undertaken. 


TUMORS  OF  THE  VAGINA 

Primary  tumors  of  the  vagina  are  rare.  Cysts,  myomas,  sarcomas, 
and  carcinomas  make  up  the  majority  of  them.  The  vagina  is  involved 
more  often  by  extensions  of  tumors  from  other  organs,  notably  from 
the  uterus,  rectum,  and  bladder. 

Cysts. ^ — Small  cysts  varying  in  size  from  a  pea  to  a  hazelnut  are  not 
uncommon,  and  sometimes  they  are  of  such  size  as  to  encroach  markedly 
upon  the  lumen  of  the  vagina.  Vaginal  cysts  are  probably  derived  from 
Gartner's  duct.  They  appear  as  smooth,  tense  cysts  projecting  into  the 
vagina.  Their  walls  are  made  up  for  the  most  part  of  fibrous  tissue 
with  an  admixture  of  smooth  muscle  fibers.  They  are  lined  b}^  colum- 
nar epithelium  which  is  sometimes  ciliated.  Gland-like  eversions  of 
cell  columns  into  the  walls  of  the  cysts  are  sometimes  observed,  and 
occasionally  the  epithelium  is  stratified.  These  peculiarities  of  arrange- 
ment sometimes  give  them  the  appearance  of  malignancy.  Rarely  the 
epithelium  is  flat,  sometimes  even  endothelioid  in  character.  The  tumors 
are  usually  filled  with  a  clear  thin  fluid.  Clinical  recognition  of  these 
cysts  offers  no  difficulty,  and  they  can  be  easily  removed  b}^  operation  if 
from  their  size  they  cause  inconvenience. 

Myomas.- — These  tumors  somewhat  resemble  cysts  because  of  their 
situation  in  the  vaginal  wall  and  their  globular  shape,  but  are  distinctly 
less  common  and  can  be  diff'erentiated  from  them  by  their  greater 
density.  They  are  similar  to  myomas  of  the  uterus  in  their  structure 
and  clinical  course.  Multiple  tumors  have  been  observed.  If  they 
become  necrotic,  a  very  rare  occurrence,  they  resemble  ulcerating  meta- 
static tumors.  Shelling  out  can  be  readily  accomplished,  but  may  be 
attended  by  surprisingly  free  hemorrhage. 

Carcinomas. — These  rare  tumors  have  been  noted  after  prolapse  of 
the  vagina  and  after  the  prolonged  wearing  of  pessaries,  but  in  the 
majority  of  cases  no  cause  can  be  ascribed.  They  usually  present  them- 
selves as  shallow  ulcerations  possessing  the  usual  characteristics  of 
superficial  carcinomas  of  the  mucous  membrane.     In  rare  instances  the 

^  For  literature  see  Peckham,  Amer.  Jour.  Obst.,  1910,  Ixi,  925. 

^  Veit,  Handbuch  d.  Gynakologie,  Bergmann,  Wiesbaden,  1897,  Bd.  i. 


ri MORS  (Ji  rill,  I  n:i\.i  635 

sii|Hi  hiKil  ipitluimm  is  iiu.k  t.  I  lu-  niiii  osiopu  ;ip|)(;ii  ;iiuf  is  that  ot  a 
.s(iiiaiii()us-iillicl  tairinoina.  Chief  iliniial  intiicsr  (.ciuics  in  rluir  dit- 
ttiiii nation  (i<»in  sicoiulaiy  caninoinas  ot  this  ic^ion,  and  in  no  instance 
slioiihl  thiii  |MiMiar\  iiatiin-  hi-  assiinu'd  without  a  careful  search  of 
those  rej^ions  whiic  piimai\  tumors  usually  occur.  If  priniar\'  and  not 
too  extensive  thi'\  nia\  he  excised.  Ifcirhfi  thi  hhidder  or  rtctuin  art- 
involved  palHation  with  acetone  as  tniploN  id  in  can  inonia  of  the  ctr\ix 
wdl  <i;ive  more  satisfactor\-  results. 

Sarcomas.'  In  chiKInn  a  ver;,  chaiacttiistic  type  of  sarcoma  is 
sometimes  ohserved.  These  tumors  he^in  as  a  Hat  mass  on  the  vaginal 
wall,  from  which  sprinji;  projections  which  the  Germans  have  character- 
ized as  "^rape-like."  The  entire  vagina  becomes  filled  with  this  mass, 
which  iiKi)  in  extreme  cases  protrude  from  the  \ul\a.  The  cervix 
becomes  involved  and  the  vaginal  wall,  the  paravaginal  tissue,  and 
bladder  are  successively  invaded.  Histologically  they  are  composed  of 
spmdle  and  round  cells  with  a  sparse  intermixture  of  striated  muscle 
fibers,  which  suggests  a  relationship  to  the  teratoid  tumors.  Their 
clinical  recognition  offers  no  difficulties  and  the  treatment  promises 
little  prospect  of  cure. 

In  adults  sarcomas  of  the  common  type  are  observed.  rhe\-  are 
usually  globular  and  fibrous,  or  they  ma\-  be  cellular  and  may  infiltrate 
the  vaginal  wall  diffusely-.  All  cell  t\pes,  even  giant  cells,  have  been 
observed.  The  very  cellular  types  are  sometimes  ver\'  vascular,  and  if 
the  surface  becomes  eroded  alarming  hemorrhages  may  ensue.  It  is 
probable  that  syncytiomas  have  been  mistaken  for  this  t\'pe  of  tumor. 

Rare  Tumors. — Not  sharpl\'  defined  from  the  vascular  sarcomas  are 
endotheliomas  presenting  like  characters.  But  three  cases  appear  in  the 
literature  and  their  histological  status  is  not  clearly  defined.  Teratoid 
tumors  have  been  reported  but  their  exact  location  was  not  satisfactorih- 
made  out.  They  were  probably  parauterine  and  extended  beneath  the 
vagina. 

^  Pick,  Arch.  f.  Gyniik.,  1896,  xlvi,  191. 


CHAPTER  XLII 

TUMORS  OF  THE  MALE  GENITAL  ORGANS 

TUMORS  OF  THE  PENIS 

Tumors  of  the  penis  aside  from  carcinoma  are  rarities.  The  important 
point  in  the  study  of  tumors  of  this  region  is  the  early  differentiation 
of  benign  tumors  from  the  enormously  more  frequent  malignant  disease. 

Carcinoma. — The  frequency  of  carcinoma  of  the  penis  is  placed  by 
Paget  and  Sibley  at  i  per  cent.,  b}'  v.  Winiwarter  at  2.5  per  cent.,  and 
by  Billroth  at  3  per  cent,  of  all  carcinomas. 

Etiology. — Phimosis  is  generally  mentioned  as  the  chief  predisposing 
cause.  Confirming  this  is  the  statement  of  Travers  that  carcinoma  of 
the  penis  is  not  observed  in  Hebrews.  Demarquay  observed  42  cases 
of  phimosis  in  ^j  cases  of  carcinoma,  while  Kaufmann  noted  only  28 
in  his  series  of  158  cases.  The  tight  prepuce  is  believed  to  keep  up  a 
constant  irritation  by  retaining  smegma,  secretions,  and  foreign  sub- 
stances. The  disease  in  3'oung  persons  especially  has  been  ascribed  to 
phimosis  by  Thiersch.  The  influence  of  phimosis  has  probably  been 
overestimated,  since  the  frequency  of  phimosis  in  general  has  not  been 
taken  into  account.  Carcinomas  of  the  glans  have  been  observed  m 
cases  where  circumcision  has  been  performed,  as  noted  by  v.  Bruns  and 
Billroth.  Schuchardt  was  the  first  to  call  attention  to  a  condition 
which  because  of  its  resemblance  to  psoriasis  buccalis  he  named  psoriasis 
preputialis.  This  condition,  like  the  similar  disease  of  the  mouth,  con- 
sists of  a  piling  up  of  the  superficial  cells  of  the  epidermis.  The  eleidm 
zone  becomes  much  broadened  and  the  interpapillary  spaces  disappear. 
The  superficial  cells  are  smooth  and  glistening  white.  This  condition 
has  been  observed  frequently  in  the  region  of  carcinomas,  and  tends 
to  disappear  when  the  newgrowth  is  removed.  The  actual  connection 
between  it  and  carcinomas  is  still  uncertain.  Demarquay  laid  particular 
stress  on  the  etiological  importance  of  chronic  syphilitic  ulcers.  Several 
cases  have  been  reported  which  began  at  the  site  of  old  chancres.  In 
rare  instances,  carcinomas  develop  in  the  corpora  cavernosa,  secondarily 
to  prostatic  and  rectal  growths. 

Pathology. — Carcinoma  of  the  penis  may  be  described  under  two  forms  : 
The  first  and  more  frequent  is  a  fungous  cauliflower-like  growth;  the 
second,  and  much  rarer,  is  a  superficial  ulcer  covered  with  fine  nodules 


TCMOkS  or   Till:    I' EMS 


03^ 


(  Mfi.  452).  In  this  r\  |ii-  tluir  IS  iisii:ill\  t-xrcnsivc  infiltr;iti()ii  lnt(j  the 
(IcipcT  tissues,  hut  without  ukc  ratiDii.  I  he  tiibt  t}'pe  frequenti}'  begins 
as  a  moist,  iiclchsli  papillary  growth,  with  mtf^ular  suifaic-  and  a  dt-nsi- 
iiihltratitl  hoickr  (l-i^.  453)-      I  lu- 

txcntions    collect    in    tin-    cKfts  of  Vn..  452 

tin-  lingular  surface,  and  a  foul 
mass  lesults.  lliese  tumors  resem- 
ble similar  growths  of  the  cervix, 
ami,  Iiki-  rluni,  hicak  down  and 
form  crateriform  ulcers  (Fiji.  454). 
T  he  destruction  of  tissue  is  some- 
times very  rapid,  and  extends  both 
around  the  ulans  and  down  the 
shaft  (Fig.  455).  The  urethra  may 
at  first  be    compressed    and    later 

opened  by  the  ulcerating  process,  so  that  if  there  has  been  an\'  inter- 
ference with  the   passage  of  urine  the  obstruction   ma\-  be   relieved  in 


^ 


Carcinoma  of  the  penis  infiltrating  a   large 
part  of  the  glans. 


Fin.  453 


Beginning  tungating  carcinoma  of  the  penis. 

this  manner.  These  ulcerations  may  extend  to  the  corpora  cavernosa 
and  cause  extensive  or  even  fatal  hemorrhages.  The  destruction  may 
be  so  extensive  that  the  whole  penis  disappears  and  an  ulcer  spreads 


638 


TUMORS  OF  THE  MALE  GENITAL  ORGANS 


over  the  pubes  toward  the  inguinal  regions.  When  the  ulcer  starts 
beneath  a  tight  foreskin  it  begins  always  on  the  penile  surface.  As  it 
enlarges,  the  tension  of  the  skin  increases,  because  of  the  induration 
which  is  always  present,  which  aggravates  the  phimosis.  The  tumor 
thus  enclosed  erodes  the  glans  largely  from  the  retained  secretions. 

It  was  formerly  believed  that  the  lymph  glands  are  seldom  invaded, 
but  the  recent  researches  have  shown  that  such  an  occurrence  is  not 
uncommon.  According  to  Kiittner,i  the  extension  takes  place  by  the 
deep  lymphatics  following  the  dorsal  vein  of  the  penis  over  the  pubic 
arch,  where  a  gland  is  sometimes  found,  and  hence  to  the  inguinal  glands. 
Channels   also   pass   along   beside   the   spermatic   cord   to   terminate   in 


Fig.  454 


Fig.  455 


Carcinoma  of  the  corona  of  the 
penis. 


Carcinoma  of  the  glans  penis,  with  secondary 
ulcers  upon  the  dorsum  and  atthe  pubic  junction. 


glands  along  the  external  iliac  veins.  The  lymphatics  of  the  urethra 
pass  below  the  symphysis  and  terminate  in  a  plexus  about  the  prostatic 
urethra.  Metastatic  formations  in  other  regions  of  the  body  are  rare. 
Kaufmann  could  find  records  of  only  6  cases. 

Symptoms. — The  frequency  with  which  the  affection  begins  as  a  small 
wart  makes  it  important  to  observe  closely  such  growths,  especially  in 
persons  past  middle  life.  White  and  Martin  believe  that  induration  or 
ulceration  of  these  growths  is  alone  enough  for  a  diagnosis.  In  common 
with  most  skin  carcinomas,  the  beginning  is  not  attended  by  any  marked 
symptoms.  Pain  is  usually  slight  or  entirely  absent.  After  the  1}  mphatic 
glands  are  involved  the  pain  is  apt  to  be  greater,  and  may  radiate 
into  the  inguinal  region    or    toward    the    perineum.     The  growth  then 


iVerhandl.  d.  deutsch.  Gesellsch.  f.  Chir.,  1899,  ii,  I18. 


77. I/O /^.S  or  Till:   I'ESIH 


iWW) 


presfius  tlu    <)icliii.ii\    ;ip|Hai;irui- of  taninoma     iiuliiiatccl  hast-,  caiuii 
pliijis,  ami  tlu-  likr. 

Diagnosis.  Patients  usually  ilo  not  sttk  advice  until  the  disease  has 
heconie  thoroughly  developed,  and  the  diagnosis  is  then  eas\'.  ^'et  it  is 
necessary  to  renieniher  a  vaiiet)'  ot  corulitions  mi  order  to  avoid  error. 
I  he  chul  ol  these  is  s\  phditic  condv  Ionia.  I  lusc-  do  not  have  indurated 
honlers,  hut,  on  the  contraiy,  are  niovahle  upon  their  hase..  1  he  tendenc\' 
of  caicMiomas  to  form  ulcers  and,  aho\e  all,  the  cancer  plugs  are  enough 
to  pic\  t  lit  error,  in  case  of  clouht,  the  advice  of  I  hiersch  ma\'  be  followed 
and  A  rlu  lapeutic  test  applud  for  two  or  three  weeks. 


1 

<-..  4^6 

■ 

i 

HRTm^^^^^I 

i 

_^bf 

ij^^^^^H 

Llcer  rtrst-mblinii  csthionitriic. 


1  he  common  error  is  to  overlook  a  carcinoma  complicated  b}-  phimosis. 
Here  it  is  well  to  remember  the  advice  of  Kaufmann,  always  to  think 
of  carcinoma  in  phimosis  with  suppuration  and  discharge.  The  condi- 
tion of  the  lymph  glands  may  give  the  clue,  especially  since  the\-  are  more 
dense  in  malignant  infiltration  than  in  simple  inflammation.  Hard 
chancres  may  resemble  the  ulcerative  form  of  carcinoma,  but  can  be 
distinguished  by  the  therapeutic  test  in  a  few  weeks  if  other  means  are 
not  sufficient.  The  same  may  be  true  of  severe  phagedenic  chancres. 
These  usually  respond  to  vigorous  local  treatment.  Dr.  Castle  has 
recently-  observed  an  ulceration  of  the  penis  which  in  course  and  general 
appearance  (Fig.  456)  resembled  esthiomene  as  observed  on  the  vulva. 

Treatment. — Nothing  but  removal  of  all  the  diseased  parts  can  be 
considered.  Theoretically,  in  those  instances  in  which  the  newgrowth 
begins  in  the  foreskin  it  has  been  proposed  that  it  would  be  permissible 


640  TUMORS  OF  THE  MALE  GENITAL  ORGANS 

to  remove  the  foreskin  alone.  It  is  doubtful,  however,  if  cases  are  ever 
seen  this  early,  so  that  practically  the  operation  must  be  removal  of  a 
part  or  all  of  the  penis.  For  convenience  the  removal  of  a  part  or  all 
of  the  pendulous  portion  is  called  amputation,  while  removal  from  the 
pubic  arch  is  called  extirpation. 

Which  operation  is  to  be  done  depends,  of  course,  on  the  extent  of  the 
growth.  The  rule  is  laid  down  by  Kaufmann'^  that  the  amputation 
may  be  made  i  cm.  to  2  cm.  back  of  the  edge  of  the  growth.  In  begin- 
ning tumors  of  the  glans  it  is  permissible  to  amputate  in  the  region  of 
the  corona,  but  in  all  instances  the  inguinal  glands  must  be  removed. 
The  operation  recommended  by  Nicoll-  seems  to  meet  all  requirements. 
He  makes  two  incisions,  one  in  each  groin,  converging  to  the  root  of 
the  penis.  An  incision  is  then  extended  along  the  penis  to  the  point 
where  the  amputation  is  to  take  place,  where  it  is  met  by  a  circular 
incision.  This  permits  removal  of  the  regional  glands  and  the  dorsal 
lymphatics.  Nothing  is  gained  by  the  removal  of  the  testicles,  and  the 
mental  depression  is  less  if  they  are  allowed  to  remain. 

The  results  of  operative  treatment  have  been  remarkably  good  accord- 
ing to  Kiittner,  whose  statistics  show  59.5  per  cent,  of  cures. 

Rare  Tumors. — Sarcoma. — These  tumors  are  exceedingly  rare.  They 
occur  in  the  erectile  tissue  exclusively.  Primary  tumors,  chiefly  round- 
celled  or  melanotic,  have  been  observed  in  a  few  instances;  a  few  were 
secondary,  usually  from  the  testicle.  They  are  characterized  by  a  rapidly 
enlarging  mass  within  the  substance  of  the  penis.  Amputation  may  be 
tried  in  early  cases. 

Wens. — Atheromatous  cysts  may  occur  on  the  penis.  They  are 
seldom  larger  than  a  pea  or  hazelnut,  and  possess  no  special  char- 
acteristics. 

Papillomas. — These  are  not  so  rare.  Aside  from  those  associated  with 
venereal  diseases,  small  papillomas  are  not  infrequently  observed.  Much 
more  rare  are  the  larger  warty  formations  which  correspond  to  those 
situated  upon  the  hand.  They  present  similar  features,  and  like  them 
may  form  extensive  keratoses.  After  the  hand  and  forehead  this  is  the 
region  most  frequently  involved  in  the  so-called  horn  formation.  Here 
as  elsewhere  they  may  presage  the  formation  of  carcinoma. 

Induration  of  the  Penis. — Under  this  head  is  described  a  peculiar 
condition,  probably  allied  to  the  keloids,  which  is  worthy  of  considera- 
tion because  it  is  often  diagnosticated  as  a  tumor,  especially  sarcoma. 

^  Verletzungen  und  Erkr.  d.  mannlichen  Harnorgane  und  der  Penis,  Enke,  Stuttgart, 
1886. 

^  Ann.  Surg.,  1909,  xlix,  240. 


r I  MORS  or  Till,  r i:\is 


c.ii 


Etiology.  It  IS  ohcii  .issociait  il  wiili  1  )ii|)u\  t  icn's  i.oni  rat."  fine'  aiul 
with  .ti,()iir.     ()tlur  aithiitu'  jHocesses  are  sonxiimcs  picsi-iu.- 

Pathology.  I  lu  iiuliii  ation  huoInts  liotli  toipoia  caxi-niosa,  l>c^in- 
luny,  luai"  llif  root  ot  tlu'  juiiis  ami  ixttiulmj;  ilistalwarcl  3  cm.  to  5  cm. 

Fig.  457 


liulinMiioii  (it  I  lie  penis. 

rile  widtli  of  the  induration  is  from  5  nnii.  to  15  mm.,  and  its  thickness 
about  the  same.  It  is  dense  and  immo\ahle,  and  the  outhnes  are  well 
defined  (Fig.  4^7)-  Microscopically,  it  is  composed  usually  of  connec- 
tive-tissue bundles,  thicker  than  normal  fiber  bundles  and  poor  in  cells 
(Fig.  4^8).  In  some  instances  calcareous  infiltration  has  been  observed 
anti  in  otlu-rs  cartila<ie  or  bone  formation  has  been  noted. ^ 


Fig.  458 


\j'm 


Induranon  ot  rlK-  lu-nis. 

Clinical  Course. — The  onset  is  insidious,  and    usually  the  first  s\mp- 
toms  are  those  ot  clifHcuIt\-  durin<i  erection.     Occasionallw  the  urethra 


*  Stein,  Wien.  klin.  \\  uchensclir.,  1909,  Hi,  1821. 

-  Tuffier,  Annates  des  maladies  des  organes  genito-urinaries,  1885,  iii,  401. 
^Jeffries,  Jour.  Cutan.  Dis.,  1899,  xvii,  231. 
41 


642 


TUMORS  OF  THE  MALE  GENITAL  ORGANS 


is  compressed.      They  are  painless  and   progress  to  a  degree,  and  then 
remain  stationary. 

Diagnosis. — They  are  differentiated  from  inflammations,  from  trauma- 
tism and  gonorrhea,  and  from  gumma.  The  absence  of  any  inflammatory 
reaction  or  pain  is  distinctive.  From  sarcoma  and  metastatic  carcmoma 
their  form  and  location  separate  them.  Mahgnant  tumors  are  never 
confined  to  the  location  characteristic  for  this  disease. 

Treatment.  —  No  treatment  is  of 
avail.  Galewsky  and  Hiibener^  have 
recently  recommended  excision.  If 
not  so  extensive  as  to  require  open- 
ing into  the  corpora  cavernosa  this 
treatment  seems  worth  trjnng. 


TUMORS    OF   THE   URETHRA 


f/^  risB 


■ '  -    U" 


Melanoma  of  the  urethra. 


Carcinomas  rarely  have  their  begin- 
nings in  the  urethra.  Papillomas  are 
more  common,  and  rarely  melanotic 
tumors  are  encountered   (Fig.  459). 


TUMORS    OF   THE   SCROTUM   AND    CONTENTS 

Neoplasms  of  the  scrotum  and  its  contents  are  not  common,  but  a 
variety  of  enlargements  occur  and  the  problems  of  differential  diagnosis 
are  frequent  and  often  confusing.  It  was  this  region  which  furnished 
Virchow  with  the  illustrative  cases  in  his  argument  for  including  enlarge- 
ments which  might  be  mistaken  for  neoplasms  in  a  discussion  of  tumors. 

Tumors  of  this  region  may  be  conveniently  divided  into  those  of  the 
scrotum,  of  the  tunica  vaginalis,  and  of  the  testicle  proper. 

Tumors  of  the  Scrotum. — Wens. — Wens  are  frequently  seen  in  the 
scrotum  and  are  commonly  multiple.  They  are  seldom  larger  than  a 
hazelnut,  and  are  usually  smaller.  The  yellowish-white,  cheesy  contents 
of  the  cysts  can  be  seen  through  the  thin  skin.  Their  subdermal  posi- 
tion and  their  attachment  to  the  skin  are  diagnostic.  Excision  is  the 
only  treatment,  and  frequently  because  of  their  number  this  is  a 
tedious  task. 

Dermoids. — These  differ  from  the  foregoing  in  being  situated  in  the 
median  raphe,  usually  behind  the  scrotum  and  in  front  of  the  anus. 
They   form   smooth,    globular   tumors   unattached    to   the   skin.     They 


^  Mijnch.  med.  Wochenschr.,  1902,  xlix,  1332. 


riMf^ks  or  rill:  scrotim   im)  (:fj.\rj:.\'rs  c.i;; 

shoiilil  lu'  icmoxrcl,  luit  in  ;mcmpim<^  icinox.il  it  shmilci  \h  I)<)|iu-  in 
niiiul  tluir  iliiniouls  in  this  loiaiion,  ;is  in  tlu-  s;iii;il  ii-^ion,  m;i\  have 
prolonfiations  coniu-ctnm  thcin  uiih  othii  simihii  tumors  nioii-  clitplx 
siniartd  within  rhi-  prKis. 

Fibromas.  I  hcsi-  rumors  an-  foiiiul  within  or  h« math  thi-  skin.  I  hey 
h)rm  ilinsf,  circumsirihid  masses,  sl<)ul\  i;ro\\mj;,  ami  painless.  I  hey 
are  liistinmiished  from  elephantiasis  l>y  the  relati\el\  normal  skin 
coveriiiii  them  and  i\\  the  fact  that  the  skin  is  unattached.  Krecjuentl)' 
they  ail'  closely  attached  to  the  tunica  \'a^inalis.  K.xcision  should  he 
|")ractiseil  wluii  from  then   size  the\'  cause  annoyance. 

Lipomas.  I  he  scrotum  is  sometimes  the  seat  ot  lipomas,  which  are 
generally  diBuse  and  ditter  in  no  wise  from  similar  tumors  found  in 
other  organs.  1  hey  are  sometimes  continuous  with  lipomas  ot  the  cord 
or  ot  the  abdominal  wall.  Iheir  soft,  semiHuctuating  character  and 
freedom  from  attachment  to  the  skin  make  the  diagnosis  easy.  Their 
removal  may  require  extensive  dissection,  hut  should  he  unattended 
with  difficulty. 

Elephantiasis.  This  disease  is  a  diffuse  fibrosis  of  the  subcutaneous 
connective  tissue  of  the  scrotum,  and  does  not  differ  from  similar  lesions 
elsewhere.  Usually  in  this  country  there  has  been  a  prexious  inguinal 
adenitis,  and  the  interference  with  the  return  flow  of  the  lymph  current 
leads  to  the  hypertrophy.  The  penis  may  be  simultaneousl\'  involved. 
The  enlargement  is  characterized  by  its  difFuseness  and  by  the  thickened 
congested  skin.  If  from  its  size  the  enlargement  becomes  troublesome, 
it  may  be  removed. 

Sarcoma. — These  tumors  find  almost  their  sole  representative  in  the 
melanotic  variety  extending  from  melanotic  patches  in  the  skin.  Early 
metastasis  is  the  rule.  Unless  detected  before  metastasis  occurs  there 
IS  no  adeciuate  treatment.     Otherwise,  they  should  be  freeh'  excised. 

Carcinoma. — Epithelial  tumors  which  result  from  some  form  of  chronic 
irritation  are  relativel\'  common.  Ihe  first  experimental  carcinoma 
known  was  observed  in  the  scrotum  of  chimney-sweeps.  The  irrita- 
tion of  the  soot  produces  at  first  a  scab,  under  which  the  epithelium 
develops.  Paraffin  and  certain  aniline  dyes  have  a  similar  action.  Carci- 
noma in  this  region  does  not  differ  from  carcinoma  in  other  locations, 
but  IS  more  often  multiple.  Slow  chronic  ulcerative  processes  with 
infiltrating  borders  are  characteristic.  \  enereal  ulcers  may  remain 
stationary  for  long  periods,  but  the  clean,  suppurating  surface  without 
scabs  distinguishes  them  from  carcinoma.  Wide  excision,  which  is 
made  easy  by  the  looseness  of  the  skin,  should  be  practised  and  the 
inguinal  lymph  nodes  on  the  affected  side  removed.  The  possibility 
of  producing  elephantiasis  of  the  external  genitals  by  this  procedure 
should  be  remembered,  but  should  not  deter  from  the  radical  operation. 


644 


TUMORS  OF   THE  MALE  GENITAL  ORGANS 


Tumors  of  the  Tunica  Vaginalis. — Hydrocele. — A  collection  of  fluid 
within  the  serous  covering  may  be  acute  from  trauma,  or  chronic  from 
continued  inflammation;  it  is  characterized  by  the  fact  that  it  will 
transmit  light.  An  ovoid  tumor  is  formed  which  is  distinguished  from 
solid  tumors  of  the  testicle  by  its  smoothness  and  tense  elasticity,  and 
from  hernia  because  the  cord  extends  unaltered  into  the  inguinal  canal. 

Fig.  460 


Thickened  tunica  vaginalis  in  chronic  hematocele. 


Hydrocele  is  important  in  tumor  diagnosis  because  it  is  frequently 
associated  with  malignant  disease  of  the  testicle  and  obscures  the  graver 
disease.  Tumors  in  the  testicle,  when  they  reach  the  surface,  cause  a 
serous  exudate  just  as  occurs  in  pleural  and  peritoneal  tumors.  This 
process  may  begin  before  the  patient  is  aware  of  any  aff^ection  of  the 
testicle.  A  radical  operation  for  hydrocele  should  always  be  advised, 
during  the  course  of  which  the  testicle  may  be  exposed  and  the  presence 


TUMORS  OF  THE  SCKOTIM    IM)  COS  TESTS 


()ir) 


or  absence  ot  nsriL-ular  tlisease  can  he  dctci  iniiu d.  II  tomul  noiinal, 
the  operation  ma\'  he  completed  by  Anclrews'  bottle  (jperatioii  or  by 
excision  of  the  sac.  ImoKenienr  of  the  lynijih  <ilan(ls  should  nor  be 
awaiteil  to  deterniiiu-  tlu'  (iiiestion  of  inaliji:nanc\  . 

Hematocele.      Collections  of   blood  within    the    tunica    vaginalis    lollcnv 
trauma  or  some  int1ammator\'  chanjj,e  withm   the  sac  or  testicle,  or  may 

Fig.  461 


Spermatocele. 


be  associated  with  malignant  disease.  Usually  a  sudden  enlargement 
following  trauma  is  the  history  given.  It  is  firmer  than  hydrocele, 
does  not  transmit  light,  and  is  more  apt  to  be  tender,  particularh'  while 
the  reaction  of  the  surrounding  tissue  to  the  blood  extravasation  exists. 
It  simulates  solid  tumors  of  the  testicle  except  in  the  rapidit}'  of  its 
formation.      Excision  of  the  sac  with   inspection  of   the  testicle  should 


646  TUMORS  OF  THE  MALE  GENITAL  ORGANS 

be  the  treatment.  When  hematocele  has  existed  for  a  long  time,  fibrin- 
ous thickening  of  the  wall  of  the  sac  (Fig.  460)  may  be  so  great  that 
castration  is  advisable,  particularly  in  old  persons. 

Hydrocele  of  the  Cord — The  tunica  may  be  obliterated  immediately 
above  the  testicle  and  then  be  free  for  a  variable  distance.  Accumula- 
tion of  fluid  within  these  spaces  is  characterized  by  a  smooth,  elastic 
swelling  surrounding  the  cord  and  separated  from  the  abdominal  cavity. 
Sometimes  the  peritoneal  portion  of  the  canal  is  free,  permitting  the 
fluid  to  escape  into  the  abdominal  cavity  when  the  patient  is  in  the 
recumbent  posture.  These  cysts  must  be  differentiated  from  solid 
tumors  of  the  cord;  this  can  usually  be  done  because  the  cysts  are  tense, 
elastic,  and  smooth.  In  case  of  doubt  the  aspirating  needle  may  be 
used.     They  are  cured  by  the  excision  of  the  sac. 

Spermatic  Cysts. — These  are  cysts  occurring  usually  at  the  junction 
of  the  epididymis  and  the  testicle.  They  vary  in  size  from  a  pea  to  an 
egg  (Fig.  461).  They  usually  contain  spermatozoa.  The  diagnosis 
is  usually  made  from  their  situation.  If  large  enough  to  cause  incon- 
venience they  may  be  shelled  out. 

Tumors  of  the  Testicle. — The  tumors  of  the  testicle  proper  are  usually 
difficult  of  diagnosis,  being  simulated  particularly  by  the  granulomas, 
notably  tuberculosis  and  syphilis.  The  cysts  of  the  tunica  form  lesions 
simulating  or  more  often  complicating  tumors  of  the  testicle.  These 
lesions,  inflammatory,  cystic,  tumorous,  and  neoplastic,  when  so  com- 
plicated form  clinical  pictures  very  closely  related. 

Complicated  and  confused  as  are  the  clinical  aspects  of  testicular 
tumors,  the  patholog}^,  up  until  the  recent  past  at  least,  has  been  even 
more  chaotic.  The  literature  abounds  in  descriptions  of  the  usual  types 
of  connective  tissue  and  epithelial  tumors  in  various  modifications 
and  combinations;  so  complex  are  they  that  pathologists  have  often 
complained  of  the  difficulty  of  classifying  them.  Evidence  has  been 
accumulated  which  indicates  that  many  of  these  tumors  which  after- 
ward seem  to  be  made  up  of  one  cell  type  were  really  the  end  stage  of 
more  complex  tumors.  The  recent  masterly  summary  of  Ewing^  leaves 
but  little  room  for  doubt  that  the  vast  majorit}^  of  primar\^  tumors  of 
the  testicle  are  teratoid  in  character. 

Mixed  Tumors  (Teratomas). — Waldeyer's  theory  of  parthenogenesis  lies 
at  the  basis  of  the  most  recent  views  of  the  origin  of  these  tumors,  and 
has  replaced  the  notion  of  fetal  inclusion  or  extrasexual  blastomeres 
as  an  explanation  of  them.  Ewing^  concludes  that  teratoma  testis 
arises  from   sex  cells  in   the  neighborhood   of  the   site,  whose  normal 

^  Surg.,  Gynec,  and  Obstet.,  191 1,  xii,  230. 
^  Loc.  cit.,  p.  258. 


rr.MoRs  or  riii:  scroti  \i   ixn  co.xtkxts 


c.r 


(1(.\  (.lopnunl  mil)  spt  tiiki  (o^oiiia  li;is  lucii  siippi  (  ss(  d  hiii  ssliosc  poten- 
cies icnKiin  ini.Ki  .iiul  i(;i{l\'  to  (•\|)r(s.s  t  luiiisc-U'rs  in  ilu  \;iiioiis  forms 
of   simple  oi    eomplex   rcTwtoiiias. 

I*  \  I  III  )i  (  K  ,\  .  M  (icroscopic  .1  pprardncr.  lii;iiom;is  wlieii  small  form 
tumors  wliuli  oi\ii|n  one  poll-  of  the  testis;  they  usually  distoii  the 
outiiiu-  of"  tin  testis,  and  what  remains  of  the  or^an  can  he  seen  as  a 
Hatteiuil  slull  ahout  tlie  tumor  H^ifi;.  462),  or,  more  often,  all  macro- 
scopic  trace  of  the  organ  has  been   lost  (Fig.  463).     Often   the   tumor 

Kk;.  462 


Mixed  tumor  of  the  testicle.    Testicular  remains  shown  on  the  left  border  of  the  tumor 


outhne  is  smooth  or  slightly  lobulated  (Fig.  464),  sometimes  it  is  dis- 
tinctl}'  nodulated  or  areas  of  degeneration  may  form  (Fig.  465),  or  the 
covering  ma\'  have  been  destro}'ed  and  the  tumor  protrudes  as  a  fungat- 
ing  mass.  When  rapidly  growing  they  are  elastic  and  often  semifluctu- 
ating,  but  the  slow-growing  nodular  types  are  often  dense.  On  section, 
they  are  usually  gra^'ish  white,  but  often  yellowish  or  mottled  with 
\ellow  areas,  and  frequentl}'  contain  C3'stic  or  myxomatous  areas.  Often 
hemorrhagic  areas  are  found,  or  large  sections  of  the  tumor  may  be 
necrotic. 


Fig.  463 


Teratoma  of  the  testicle,  showing  cystic  areas  within  cellular  areas. 

Fig.  464 


Mixed  tumor  of  the  testicle.    This  tumor  contains  areas  suggesting  carcinoma  and 
other  regions  suggesting  sarcoma. 


ri'MORs  or  THE  scrotum  .ixd  coxtents 


G49 


Microscopic    Structure.      I'lie     majority    of    these    tumors    have    the 
structurt'  of  carcinoma    in    \arioiis   modifications.      Alveolar  formation 

Fin.  465 


Mixed  tumor  of  the  testicle,  showing  cyst  from  softening  of  degenerated  area. 


Fig.  466 


Mi.xed  tumor  of  the  testicle.    Cells  and  connective  tissue  intermingled  in  some  areas 
like  a  sarcoma,  and  in  other  areas  an  alveolar  arrangement. 


650  TUMORS  OF  THE  MALE  GENITAL  ORGANS 

is  often  well  marked,  but  quite  as  often  it  is  indistinct,  the  cells  being 
arranged  diffusely  (Fig.  466)  as  in  sarcoma,  but  without  well-defined 
stroma;  lymphoid  tissue  is  often  prominently  in  evidence.  The  cells 
are  usually  large,  with  large  vesicular  nuclei,  prominent  nucleoli,  and 
clear  cytoplasm.     This  structure  is  often  modified  in  that  the  cells  are 

Fig.  467 


if  .Sits  *s%?«3t3!feirs 


-^        -£■•'  .  ^^^^'Z: ^i-i^  ■■^'^'l^■^^^^'*'^-^^■i■■'i'■■ 


Mixed  tumor  of  testicle,  showing  glandular  areas,  areas  of  cartilage,  and  sarcoma-like 

connective  tissue. 

smaller,  the  connective  tissue  less,  or  gland  structure  may  be  present. 
Often  areas  are  seen  which  present  the  appearance  of  endothelioma; 
this  is  particularly  likely  to  be  true  of  secondary  deposits.  The  myxoid 
tissue  and  cartilage  (Fig.  467)  which  is  found  in  many  of  them  makes 
their  origin  clear;  the  absence  from  many  of  the  tumors  of  such  evidence 
of  other  embryonal  layers  may  be  explained  on  the  ground  that  such 


'nw/fjks  or  the  scroti- m  .ixn  coxtexts 


Gol 


rissiU'  txistid  and  was  displaced  h\  the  iiioic  lapid  H,,,\stli  oKotluT  tissiio, 
or  tliat  the  c-xammation  was  not  siiIHik m  l\  i  horoiinh  to  disflosc  its 
presence. 

l-ic.  .)6H 


Gumma  of  the  testicle  after  treatment  with  potassium  iodide,  showing  normal  testicle 

and  cicatricial  areas. 


Fig.  469 


Extensive  S3'philitic  disease  of  the  testicle. 


652 


TUMORS  OF   THE  MALE  GENITAL  ORGANS 


Clinical  Course. — Mixed  tumors  are  often  of  rapid  growth,  but  in 
other  cases  three  or  four  years  may  be  required  to  reach  a  size  twice 
as  large  as  a  hen's  egg.  Their  appearance  often  follows  close  upon  a 
blow  on  the  testicle,  and  is  often  painless,  but  quite  as  often  is  attended 
by  dull  pain.  The  growth  may  retain  the  form  of  the  testicle  or  may 
be  slightly  bosselated;  the  dense  nodular  variety  is  less  often  seen.  The 
tunica  may  be  perforated  and  the  skin  become  attached;  extension  to 
the  cord  may  take  place;  metastases  spring  up  in  the  iliac  or  abdominal 

Fio.  470 


Gumma  of  the  albuginea,  producing  skin  ulceration. 


lymphatics,  often  before  the  testicular  tumor  has  attained  any  con- 
siderable size.  Usually,  however,  metastasis  in  this  region  does  not 
occur  until  after  the  original  tumor  has  been  removed.  Sometimes 
the  first  metastasis  is  at  a  distance,  particularly  in  the  lungs,  less  often 
in  the  liver. 

Diagnosis. — Syphilis  (Figs.  468,  469,  and  470)  is  most  often  con- 
founded with  testicular  tumors.  In  this  disease  the  testicle  becomes 
uniformly  enlarged,  is  smooth,  and  painless.  The  enlargement  is  quite 
rapid  and  often  other  evidence  of  the  disease  can  be  obtained  by  inspec- 


TUMORS  OF   THE  SCROTI. \f  JM)  COX  TEXTS 


O,-).'] 


tion  of  otlu r  it-^ions  of  tlic  ht)cl\-  or  from  rlu-  liistoiw  I'he  Wassermann 
reaction  or  the  therapeutic  test  with  potassium  i(Klide  will  ^ive  valuable 
evidence.  Tuberculosis  usuall\'  begins  in  the  epididymis,  invading  the 
testicle  secondarilv  (Fig.  471),  and  frecjuentl)'  causes  adhesions  of  the 
skin  before  the  testicle  is  invaded.  Tuberculosis  existing  elsewhere 
in  the  bod\-,  particularl\-  in  other  portions  of  the  genito-urinar\-  tract, 
ma\'  cause  suspicion  as  to  the  nature  of  a  doubtful  testicular  tumor. 


Fig.  471 


Fig.  472 


Tuberculosis  of  the  testicle,  showing 
caseated  masses  within  the  epididymis 
and  testicle. 


Operation  for  malignant  disease  of  the 
testicle:  a,  spermatic  vessels;  b,  lymph 
glands;  c,  retracted  colon;  d,  vena  cava; 
e,  vas  deferens. 


Often  exudate  into  the  tunica  makes  an  examination  difficult.  In  such 
instances  the  opening  of  the  sac  permits  of  a  satisfactory  inspection 
of  the  testicle. 

Treatment. — Usuallv  castration  with  removal  of  the  cord  well  up 
through  the  inguinal  canal  is  performed.  More  recenth'  more  extensive 
operations  looking  to  the  removal  of  the  gland-bearing  tissue  w^ell  up 
along  the  external  iliac,  even  to  the  spermatic  and  renal  vessels,  have 


654 


TUMORS  OF  THE  MALE  GENITAL  ORGANS 
Fig.  473 


Spindle-celled  sarcoma  of  the  testicle. 


Fig.  474 


Vi'^^t^    •  \ 


\ 


So-called  syncytioma  of  the  testicle. 


rr.\i(jRs  or  ■/•///■:  scroti  m   ixp  crjxrf.x'rs  d.').") 

luin  piojxjsid'  I  I'l^.  472).      I  Ins  tcilmKiiic  is  111  .ucord  wiili   ilic  picscnt 
pniuiplcs  of  optiation,  and  is  to  be  reconiinc-iuled. 

Rare  Tumors  of  the  Testicle.  Sarcoma,  l\'nipliosarcoma,  primarv  within 
the  testicle-  and  sjiindle-celled  tiiniois  fioin^  out  from  the  connecti\e 
tissui'  \\A\c  hetii  ohseised  I  1'  i^.  473  ).  I  he  caicniomas  repoi  l(  d  |)ioh;d)|y 
all  belong  to  excessis'e  di\'elopnient  ot  one  t\  pe  of  teratoid  cells. 
Chondionia,  myxomas,  and  myomas  are  n(j  doubt  but  teratomas. 
Syncytiomas,  existing  alone  or  m  conjunction  with  other  elements, 
ha\i'  their  origin  in  teratomas.  In  rare  instaiiccs,  more  comjilete 
tumors  (Fig.  474)  are  observed,  and  it  is  these  that  make  us  adhere 
to  the  possibility'  of  an  embrj'onal  origin  in  rare  instances. 

'  Chevassu,  Presse  med.,  1910,  xviii,  363. 


CHAPTER  XLII  I 
TUMORS   OF  THE  UPPER   EXTREMITIES 

The  extremities  are  not  so  frequently  the  seat  of  tumors  as  man}^ 
of  the  regions  already  considered,  but  the  needless  mutilation  often 
carried  out  under  mistaken  diagnosis  makes  these  regions  of  great 
practical  importance.     This  applies  particularly  to  the  arm. 

TUMORS    OF   THE   SHOULDER 

The  shoulder  may  be  considered  to  mclude  the  clavicular  and  scapular 
regions  and  the  soft  parts  covering  them  and  also  the  upper  portion  of 
the  humerus.  The  axilla,  too,  following  the  example  of  Kermisson, 
may  be  included.  The  region  contains  a  very  diverse  group  of  tissues, 
and   a  variety  of  tumors   correspondingly  great  is  found   there. 

The  shoulder  has  a  peculiar  predilection  for  lipomas  and  sarcomas. 
The  axilla  is  subject  to  a  variety  of  tumors  which  are  native  to  it, 
particularly  lipomas,  wens,  and  adenomas;  and  the  axillary  lymph 
glands  are  subject  to  secondary  involvement  from  carcinoma  of  the 
breast  and  of  the  extremity  and  from  melanotic  tumors  of  the  arm  and 
thorax.  The  supraclavicular  space  gives  rise  to  primary  and  secondary 
tumors  of  similar  variety.  The  shoulder  and  axillary  space  are  subject 
to  many  inflammatory  disturbances  which  are  often  confused  with 
neoplasms.  Taken  all  together,  the  shoulder  from  the  standpoint  of 
tumors  is  one  of  the  most  important  regions  of  the  body. 

Sarcoma. — The  most  important  tumors  of  the  shoulder  are  un- 
doubtedly sarcomas  (Fig.  475).  They  may  arise  in  the  soft  parts,  but 
usually  are  of  bony  origin  and  frequently  date  from  trauma.  When 
they  arise  in  the  upper  extremity  of  the  humerus  they  ma}^  be  either 
endosteal  (Fig.  476)  or  periosteal  (Fig.  477)  in  origin.  In  the  former 
case  the  outline  of  the  bone  becomes  gradually  lost  in  the  contour  of 
the  shoulder.  The  periosteal  type  forms  a  more  or  less  circumscribed 
tumor  which  may  be  undetected  in  the  general  enlargement,  particularly 
if  the  shoulder  is  thickly  covered  with  muscle  and  adipose  tissue.  In 
the  scapula,  because  of  the  absence  of  cancellated  tissue,  osteogenous 
sarcomas  are  usually  periosteal  in  origin.     Here,  too,  the  tumor  may 


■/■(WKJRS  or   Till.   SIIOll.DER 


g; 


be  well  ciicuiiisci  ibtcl  or  tlittusi'.  I  In-  spiiu-  ol  tin-  scwpula  is  most  tie- 
(lutiitU'  tin-  sitf,  ;iiul  111  this  loc;irioii  ruinois  are  well  exposed  to  palpa- 
tion, but  when  tbey  go  out  from  tbe  axillary  border  the  nature  and 
extent  of  tumefaction  is  much  less  readily  determined.  I'he  clavicle 
much  less  frequently  contributes  tumors,  the  external  half  being  usuall\' 
iinoKed.  riuy  are  usuall\  periosteal,  but  occasionally  they  spring  from 
the  interior  of  the  bone. 

Sarcomas  of  the  soft  parts  may  develop  in  any  ot  the  tissues  of  this 
region  and  differ  in  no  wise  from  such  tumors  in  other  regions.     Primary 

Fig.  475 


Sarcoma  of  the  shoulder. 


sarcomas  of  the  axilla  developing  from  tissue  other  than  those  alread}- 
mentioned  are  not  common.  In  man\-  of  the  reported  cases  the  possi- 
bility of  their  origin  from  inconspicuous  melanomas  of  the  arm  (Fig. 
478)  has  not  been  sufficienth*  considered.  At  any  rate,  a  sarcoma  of 
the  axilla  unattached  primarily  to  muscle,  fascia,  or  bone  is  most  fre- 
quentl}^  metastatic. 

Sarcomas  developing  from  an}-  of  the  structures  going  to  make  up 

the  shoulder  are  characterized   b}'   rapidity  of  development.     Because 

of  their  secluded  origin  within  the  shaft  of  the  humerus  or  in  the  soft 

parts  of  the  region  the  beginning  of  the  trouble  may  be  signalized  b\- 

42 


658 


TUMORS  OF  THE  UPPER  EXTREMITIES 


pain  from  pressure  within  the  bone  or  upon  some  nerve  without  it,  by 
pressure  upon  the  vessels,  or  by  interference  with  the  mobihty  of  the 
joint;  and  an  inflammatory  trouble  may  be  suspected. 

Any  or  all  of  these  symptoms  may  exist  for  a  variable  time  before 
the  tumor  is  detected.  Usually  when  the  patient  presents  himself  there 
is  already  evidence  of  rapidly  enlarging  tumor,  and  it  but  remains  to 

Fig.  476 


^■1 

■ 

■• 

iPi^^H 

^^H 

W 

^ 

^K4" 

\^m 

•i. 

^^^m 

^^1k 

i 

^E^^ii 

'  M 

■P 

)k 

Jj 

1 

m 

1^1 

\ 

Rk 

Endosteal  sarcoma  of  the  humerus. 


determine  the  point  of  origin.  The  fixation  of  one  bone  and  the  passive 
movement  of  the  other  are  our  chief  means  of  determining  this  point 
when  the  situation  is  obvious.  When  far  advanced  it  ma}^  be  difficult 
to  determine  whether  or  not  the  tumor  began  in  the  bone  or  soft  parts, 
but  usually,  when  derived  from  the  bone  the  consistency  of  some  por- 
tion declares  its  nature  or  the  direction  of  the  growth  may  indicate 
the  point  of  origin.    The  tumors  of  the  axilla  are  usually  loosely  attached 


TUMORS  or    rill:    SIIOL  I.DI-.R 


(■..")!> 


to  (lu-  surioiiiuliiiu,  tissue  aiul  souk  piiiiiaiv  iiiiuoi  m;i\  Ix  diseox  ci  cd 
in  rlu-  ri'j^ion  ot  l\  iiipluinc  cli;iin;i^e.  I  he  siihsciiiunt  roiiisi-  (tf  shoulder 
sarcomas  is  variaMc.  I'hey  usually  enlarge  pi()j:;rcssivily  and  nictas- 
tasi/e  in  sonie  of  the  internal  oi}:;ans.  Occasionally,  ulciianon  occurs 
with  secondan'  infection.  The  entire  course  is  usually  run  ni  from  one 
to  two  \ears,  hur  this  nine  may  he  exceeded. 

Fig.  477 


Periosteal  sarcoma  of  the  head  of  the  humerus. 


Diagnosis. — A  rapidly  growing  tumor  of  the  shoulder  is  in  the  majorit\- 
of  cases  a  sarcoma.  Sometimes  cases  are  observed  in  which  the  slow- 
rate  of  growth  leaves  the  question  in  doubt.  The  time  of  beginning 
may  not  have  been  accurately  observed,  and  benign  tumors,  particularly 
lipomas,  may  take  on  a  temporary  acceleration  of  growth,  and  because 
of  this  be  confused  with  sarcoma.  Such  an  error  is  impossible  if  the 
soft  irregular  lobulations  of  lipoma  are  remembered.  The  skm  cover- 
ing lipomas  is  freely  movable,  and  they  are  movable  upon  their  base, 
while  sarcomas  are  fixed  to  their  base  and  often  to  the  skin.  Sarcomas 
of  the  bones  present  greater  difficulties.  It  is  desirable  to  note  with 
care  the  anatomical  features.     Sarcomas  going  out  from  the  bone  are 


660  TUMORS  OF  THE  UPPER  EXTREMITIES 

firmly  attached  and  often  show  infiltration  of  the  soft  parts.  Other 
tumors  attached  to  the  bone,  osteomas  and  chondromas,  are  of  slow 
growth  and  their  densit}^  is  characteristic;  in  addition,  the  constricted 
base  of  the  osteomas'  gives  further  evidence  of  their  benignanc}'. 

Expanding  tumors  within  the  bone  may  cause  pain  before  obvious  en- 
largement occurs.  The  A-rays  may  give  valuable  evidence  of  such  tumors; 
they  are  most  often  metastatic,  usually  from  hypernephroma  (Fig.  479). 
If  evidence  of  a  kidney  tumor  is  present,  the  probability  of  the  lesion 
within  the  humerus  being  metastatic  hypernephroma  is  greater  than  that 

Fig.  478 


/ 


Melanoma  of  the  axilla  from  a  melanoma  of  the  arm. 

a  sarcoma  exists.  When  a  tumor  in  the  region  of  the  shoulder  is  examined 
the  bone  from  which  it  arises  may  be  determmed  b}'  fixing  one  bone 
and  making  passive  motion  with  the  other.  In  case  of  the  scapula  and 
clavicle  this  cannot  be  done,  and  it  is  sometimes  necessary  to  await  the 
incision  at  operation  to  determine  this  point.  Axillary  lipomas  are 
easily  recognized,  but  when  they  are  situated  beneath  the  axillary  fascia 
they  may  be  obscured  because  their  mobility  is  impaired.  The  histor}' 
of  slow  growth  must  be  the  chief  dependence  in  such  instances;  often, 
too,  they  are  congenital.     Sarcomas  elsewhere  (especially  in  the  breast) 


77    l/OA'N  or   Till'.   Sllori.DI.R 


m 


slioukl  ;il\\;i\s  he  thought  ot  in  tascs  of  (iiicst  loii.iMt  ;i\ill;ii\  tumors. 
C'()nncnir;il  i.\  sts,  Uccaiisr  ot  loiijj,  duiation  and  elastic  feel,  may  be  mis- 
taki'ii  tor  lipomas,  ami  aspiiarion  ma\'  he  ncccssarv  to  distiiifiinsh  them; 
because  ot  tluii  iaiii\  c\sts  shoiilil  not  he  diagnosticated  without  this 
e\idcnce.  Angiomas  an'  comprissihK',  hut  rchll  when  the  pressure  is 
removed;  when  deepl\-  seated  rluii  presence  ma\-  be  suj^f^ested  b\'  the 
superficial  telan<iiectasis.     'I"he\    m;iy   be  mistaken  for  aneur)-sms,  espe- 


Ki...  , 


7' I 


Metastatic  hypernephroma  of  the  head  of  the  humerus. 


ciall\'  ^^•hen  supraclavicular,  m  which  case  they  ma\'  transmit  the  impulse 
from  the  subclavian  artery-.  Examination  of  the  heart  and  pulse  must 
be  depended  upon  to  prevent  this  error,  besides  positive  signs  of  aneurysm 
are  wanting. 

A  variety  of  other  conditions  ha\'e  been  confused  with  tumors  ot 
the  shoulder.  Inflammator}'  lesions,  particularly  those  attended  by 
tumefaction,  little  pain,  and  slow  enlargement,  are  frequently'  mis- 
taken for  tumors.     Pain  before  the  appearance  of  the  tumor  may  lead 


662  TUMORS  OF  THE  UPPER  EXTREMITIES 

to  the  diagnosis  of  rheumatism  or  neuralgia;  in  such  cases  the  x-rays 
are  of  great  value.  Tuberculosis  involving  the  bone  often  leads  to  con- 
fusion with  tumor,  particularh^  when  there  is  much  effusion  into  the 
joints;  in  both  the  temperature  may  be  elevated,  but  in  tumor,  espe- 
ciall}^  sarcoma,  the  joint  surfaces  are  nearly  always  unaffected  and  there 
is  no  muscular  spasm.  Bursitis  is  usually  attended  by  pain  and  hydrops, 
and  is  distinguished  by  its  location  and  tense  elasticity,  and  definitely 
b}^  aspiration.  Swelling  of  the  arm  usually  indicates  infiltration  about 
the  vessels,  but  bony  tumors  may  compress  vessels  and  cause  swelling. 
In  axillary  tumors  a  possible  primary  source  should  be  thought  of  and 
the  breast  examined  for  nodules  and  the  tributary  area  inspected  for 
primary  melanotic  tumors.  Syphilis  has  been  repeatedly  mistaken  for 
malignant  tumor  of  the  shoulder,  the  clavicle  being  particularly  liable 
to  be  affected  by  a  syphilitic  periostitis  with  a  spindle-form  enlarge- 
ment; but  the  lesion  is  usually  more  painful,  particularly  at  night,  than 
is  sarcoma.  Similar  processes  on  the  scapula  have  been  noted  with 
similar  signs.  Tn  such  conditions  syphilis  should  always  be  thought 
of  and  other  evidence  of  the  disease  searched  for,  and  in  cases  of  doubt 
the  therapeutic  test  applied. 

Metastatic  Tumors  of  the  Bone. — The  upper  end  of  the  humerus 
is  occasionally  the  site  for  metastatic  tumors.  The  kidney  is  usually 
the  primary  site,  and  in  tumors  of  the  humerus  the  possibility  of  the 
existence  of  a  renal  tumor  should  be  considered.  Less  often  other  types 
of  tumor,  notably  tumors  of  the  thyroid,  and  less  often  carcinomas, 
form  early  metastasis  in  the  bone  at  this  region.  When  they  are  carci- 
nomatous the  primary  tumor  is  nearly  always  in  evidence,  but  in  some 
instances  a  smooth  mammary  carcinoma  may  be  overlooked,  and  the 
first  object  to  attract  attention  is  the  tumor  in  the  bone. 

Metastatic  tumors  of  the  bone  have  been  operated  under  the  impres- 
sion that  the}"  were  primar}^.  When  secondary  to  slowly  developing 
hypernephromas  long  intervals  of  freedom  have  been  recorded.  As 
much  cannot  be  said  for  secondary  sarcomas  and  carcinomas. 

Carcinomas. — Skin  carcinomas  in  the  region  of  the  shoulder,  particu- 
larly the  clavicular  region,  are  by  no  means  uncommon.  They  exist  as 
spreading  ulcerations  with  hard  border  and  necrotic  base.  Not  infre- 
quentl}^  the}^  extend  deeply  and  involve  the  bone.  The  carcinomas 
involving  the  interior  of  the  bones  of  this  region,  of  which  a  consider- 
able number  exist  in  the  older  literature,  have  in  the  light  of  recent 
knowledge  been  determined  to  be  metastatic  tumors. 

Lipomas. — The  shoulder  is  one  of  the  most  frequent  sites  of  lipoma  (Figs. 
480  and  481).  They  form  rounded,  soft,  lobulated  masses,  here  as  else- 
where, but  occasionally  are  so  diffuse  as  to  be  confusing.  Their  growth 
is  almost  invariably  slow,  occasionally  interrupted  by  periods  of  accelera- 


TIMORS  or  Till'.  siiori.Di-.R 


(i(i:-; 


rioii.  Tin  ii|)|ui  postciioi  region  is  most  trc(iiunt  ly  iinolvcd,  occasioii- 
all\'  sin;ill  lohulcs  jj;iow  about  rlu  vessels  and  nerves.  Ihe  axilla  ma)'  be 
invailid  li\  tumors  arisinji;  elstwhere,  bur  not  infre(juenrl\'  it  is  tbe  site 
of  j-)rimar\    lipoma   (Fig.  4«S2j.      llie  supraclavicular  fossa  is  a  common 

In;.  4.*^o 


Lipoma  of  the  shoulder. 


site.  These  ma}'  be  congenital  and  bilateral,  and  are  sometimes  com- 
bined with  bloodvessels  forming  angiolipomas  resembling  those  described 
in  the  cheek.  Lipomas  of  the  shoulder  may  attain  huge  dimensions  and 
cause  disturbance  only  from  their  bulk. 

Osteomas. — Bony  tumors  of  benign  nature  are  encountered  about 
the  shoulder.  The}-  usually  develop  from  the  scapula  or  its  processes; 
more  rarely  from  the  humerus.     Occasionall)',  bon}-  outgrowths  from 


664 


TUMORS  OF  THE   UPPER  EXTREMITIES 
Fig.  481 


Lipoma  of  the  shoulder. 
Fig.  482 


Primary  lipoma  of  the  axilla. 


TCMfJkS  OF  THE  S/IOCLDJ-R 


CO.") 


the  region  ot  rlu'  cpipli\  stal  lines  occui'  as  an  expression  of  error  in 
development  (exostosis  carrilaginea).  Ihe  giowrh  is  verv  slow,  the 
tumor  dense,  and  usually  has  a  constricted  base.  1  he\'  ma\'  cause 
disturbance  when  by  their  size  they  impinge  against  the  surrounding 
bones,  thus  lessening  rlu-  movements  of  joints.  When  growing  into 
the  brachial  plexus,  jiain  may  be  caused  or  compression  of  vessels 
ma\'   produce   disturbance  of   circulation   in    the   arms. 

Fig.  483 


Chondroma  of  the  scapula. 


Chondroma. — Cartilaginous  tumors  about  the  shoulder  should  always 
be  regarded  with  suspicion,  for  usually  they  are  combined  with  sarcoma- 
tous tissue,  and  rapidly  growing  cartilage  tumors  should  be  regarded 
as  malignant  (Fig.  483).  More  rareh"  ecchondromas  develop  in  this 
region.  Benign  chondromas  occur  more  often  in  the  clavicle  and  may 
here  attain  marked  size  (Fig.  484). 

Cysts. — Aside  from  deltoid  bursal  cysts  and  those  common  to  the 
skin  in  other  regions  (wens),  congenital  cAsts  are  sometimes  observed 


666 


TUMORS  OF  THE  UPPER  EXTREMITIES 


in  the  axilla  which  are  similar  in  origin  and  character  to  those  observed 
in  the  neck.  They  are  soft,  fluctuating  cysts,  of  slow  growth;  they 
fill  out  the  axilla,  and  like  those  of  the  neck  may  cause  disturbance 
by  mechanical  interference.  Not  infrequently  they  are  continuous  with 
similar  cysts  of  the  neck,  or  cysts  may  exist  in  both  situations  without 
any  intermediate  portion. 

Angiomas. — Aside  from  combinations  with  fatty  tissue,  as  angio- 
lipomas,  bloodvessel  tumors  may  occur  in  the  axilla.  They  are  usually 
venous,  forming  soft  boggy  masses  common  to  those  conditions.  These 
characteristics  may  be  masked  by  the  fascia,  which  because  of  its  density 
does  not  permit  the  soft  tumor  to  protrude.  Telangiectasis  of  the  skin 
may  exist  about  the  shoulder  and  may  be  indicative  of  the  nature  of 
such  questionable  axillary  lesions. 

Fig.  484 


Chondroma  of  the  clavicle. 


Treatment. — Lipomas  should  be  removed  when  discovered;  if  allowed 
to  remain  they  tend  to  progressive  enlargement.  Those  on  the  cap  of 
the  shoulder  are  easily  removed  under  local  anesthesia.  Those  in  the 
axilla  and  supraclavicular  space  require  careful  dissection  under  general 
anesthesia.  Axillary  cysts  are  difficult  of  management.  When  asso- 
ciated with  a  similar  lesion  of  the  neck  a  deep  connection  between  them 
is  frequent  and  complete  dissection  requires  exposure  of  the  axillary 
and  supraclavicular  vessels.  A  partial  removal  is  usually  followed  by 
an  obliteration  of  the  remainder  of  the  cyst.  Those  who  have  en- 
countered axillary  angiomas  have  been  silent  as  to  the  treatment 
employed,  and  information  is  lacking  except  the  warning  against 
incising  them  as  abscesses.     Osteomas  and  chondromas,  because  of  the 


TlMOkS  or  Till'.     IKM,   l.l.lUJii  ,     IM)  lORL.lR.M 


m'i 


consn  KtccI  base,  air  iasil\  icinoscil  l)\-  a  stroke-  ot  rlu-  chisel  aftc-r  the 
soft  parts  ha\i'  httii  i  ct  ractitl.  They  should  hi-  \M(U-I\-  excised  If"  there 
is  any  disjiosition  to  rapid  j^iowth  even  if  the  tissue  seems  to  he  henij^n. 
I  he  (luestion  of  treatment  oF  sarcoma  of  the  shoulder  has  been  clariHed 
in  a  recent  paper  h\'  Nancrede'  in  which  he  showed  that  it  is  question- 
able if  a  single  case  of  sarcoma  has  been  cured  by  interoscapulothoracic 
amputation.  This  is  in  the  line  with  recent  views  on  the  subject.  Local 
operation  would  seem  to  be  the  treatment  of  choice;  Cole3''s  fluid  may 
be  resorted  to  or  the  condition  left  untreated. 


TUMORS    OF   THE   ARM,    ELBOW,    AND    FOREARM 

The  tumors  of  the  lower  part  of  the  arm  and  the  upper  part  of  the 
forearm,  including  the  region  about  the  elbow,  ma\-  be  considered 
together.  This  grouping  is  made  because  many  of  the  tumors  of 
this  region  are  confused  with  the  diseases  involving  the  elbow-joint. 

Fig.  485 


Fungous  melanoma  of  the  arm. 


Sarcoma. — Sarcoma  may  develop  in  the  soft  parts  about  the  elbow 
and  arm,  usually  from  the  fascia  or  from  melanomas  of  the  skin  (Fig. 
485).     Most  important  are  those  which  spring  from  the  bone.     They 


^  Ann.  Surg.,  1909,  1,  I. 


668 


TUMORS  OF  THE  UPPER  EXTREMITIES 


are  most  frequently  periosteal  (Figs.  486  and  487),  but  may  be  endos- 
teal, and  all  cellular  types  are  represented.  Those  which  develop  in 
the  soft  parts  are  usually  encapsulated  and  are  somewhat  movable; 
their  partial  fixation  is  due  to  their  attachment  to  the  fascia  from 
which  they  spring.  Their  rate  of  growth  varies  greatly,  but  they  are 
usually  of  relatively  rapid  growth;  but  developing  within  or  beneath 
the  skin,  particularly  when  sessile,  are  often  of  slow  growth.  The  pen- 
osteal  variety  are  deep  seated,  indefinite  tumors  usually  of  relatively 

Fig.  486 


Periosteal  sarcoma  of  the  shaft  of  the  humerus. 


rapid  growth,  which  soon  infiltrate  the  surrounding  tissue.  The  endosteal 
variety  expand  the  bone,  producing  a  spindle-formed  enlargement  when 
some  distance  from  the  jomt,  but  when  situated  close  to  it  this  appear- 
ance is  partly  lost  because  of  the  mcreased  dimensions  of  the  bone  as  it 
approaches  the  joint. 

Diagnosis. — The  rapid  development  of  sarcoma  differentiates  it  from 
lipoma;  the  fixity  of  the  former  and  the  mobility  of  the  latter  establishes 
the  diagnosis.  Sarcomas  are  most  often  confused  with  inflammatory 
diseases   of  this    region.      These   may   be    inflammations   of   the    bone, 


yr i/oA'.s-  or  riii-  ,irm,  i:i.H()Ii\  .ixd  iore.ium 


fi(39 


l>;irticiil;irl\  ostcoim  ilii  is  ot  ;i  tlnonn.-  tli;ii  ;ui(i  or  tLil)crciilosis  about 
till'  joint.  All  intl.mimaroi  \  atiiction  ma\  he  distinguished  by  impaired 
tunctioii,  rlu-  nion-  maikiil  tin-  more-  acuri-  tin-  i)rocess.  The  osteo- 
niyelitic  pioctssrs,  howixtr,  aic-  chionic  in  character  and  excite  an 
osteophistic    rather    than    an    inHammatoiy    reaction,    with    freciuenti)' 

Fig.  487 


,;itfiSJMBL55^ 


Periosteal  sarcoma  of  the  forearm. 


a  histon'  of  a  previous  more  active  process;  they  might,  therefore, 
cause  some  confusion.  Sarcomas  of  the  soft  parts,  either  primar\-  or 
secondary  to  a  periosteal  origin,  are  sometimes  confused  with  chronic 
inflammator\-  processes,  the  more  so  because  not  infrequenth'  there  is 
a  history-  of  traumatism.  Myositis,  particularh'  of  the  biceps,  frequenth' 
diagnosticated   sarcoma,  may  be  recognized  b}-  the  sharp  Hmitation  to 


670 


TUMORS  OF  THE  UPPER  EXTREMITIES 


Fig.  488 


this  muscle  (Figs.  488  and  489),  and  its  movements  with  it.     Myositis 
often  is  attended  by  impaired  function.     When  bone  has  been  formed 

it  is  easily  demonstrated  by  the  A;-rays, 
which  show  a  spindle-formed  mass  unat- 
tached to  bone.  In  the  fibrous  tj^pe  of 
myositis  the  cellular  invasion  may  be 
such  as  to  resemble  sarcoma  (Fig.  490), 
but  can  be  distinguished  from  it  by  the 
presence  of  numerous  polynuclear  cells. 
Sarcomatous  tissue  has  more  elasticity 
and,  what  is  more  important,  develops 
more  rapidly  in  the  latter  period  of  time, 
while  in  inflammatory  affections  the  de- 
velopment is  first  rapid  then  slow.  In- 
flammatory affections  of  the  joints  are 
characterized  by  a  limitation  of  motion 
because  of  muscular  action;  in  case  of 
tumors,  limitation,  if  present,  is  caused 
only  by  tissue  contact. 

Treatment. — Sarcomas  of  the  soft  parts 
and  those  of  the  endosteum  when  of  slow 
Myositis  ossificans  of  the  biceps,     growth   admit  of  conservative  treatment, 


Fig  489 


Myositis  ossificans,  biceps:    a,  bone  trabeculae;  b,  b,  muscle  cells  that  have  escaped 
destruction;  c,  areas  of  newly  formed  connective  tissue. 


'j'l  WKjRs  Of  ■/■///■:  ./k.M,  1:1. Hon,  ./xn  ioklirm              cti 

hut  till-  pi  ri().sii;il  t\|n-,  p;ii  t  iiiilai  l\  ;iltir  tlic  soft  |);iits  l);i\i-  hi-c-n 
m\;ulicl,  ;iic  lust  iiiatiil  1m  ;im|)iit;i  t  loii.  Ihc  sariitui-  ol  sott  parts 
\\ill  m  most  msiaiuis  in-  so  ^riar  that  the  arm  will  ix-  iist-lcss.  Ampu- 
tation will  lari'ly  cure,  Init  it  will  rcluxt  ilu  patient  from  the  si^lit 
of  graciiKill)'  approachinfi;  death. 

Fio.  490 


/ 


a 


%:^^^--  c 


•    V 


/  .  i 


.':    i 


»■' 


Multiple  fibrosis  of  the  biceps:    a,  muscle;  b,  partly  preserved  muscle  fibers  within 
the  tumor;  c.  newly  formed  cellular  fibrous  tissue. 

Carcinoma. — Malignant  epithelial  tumors  about  the  elbow-joint  are 
rare;  but  occasionally  a  spreading  superficial  skin  carcinoma  is  observed. 
Thev  progress  slowly  and  have  the  usual  qualities  of  such  growths. 
Carcinomas  are  often  simulated  by  syphilitic  ulcers.  The  rapidit}'  of 
development  of  the  latter  and  the  deep  ulcers  with  soft  margins  should 
differentiate  them.  A  number  of  arms  have  been  received  at  the  labora- 
tor}'  which  were  amputated  for  syphilis. 

Treatment. — Carcinomas  when  seen  earh"  may  be  treated  by  excision. 
Often  they  are  neglected  until  the  deeper  parts  are  involved  and  then 
amputation  must  be  done. 

Lipomas. — Tumors  which  develop  from  the  subcutaneous  fat  are 
very  common  in  this  region  (Fig.  491).  They  are  often  multiple  and 
rarely  attain  a  large  size.  They  appear  as  soft,  globular,  seldom  lobu- 
lated,  movable  tumors  situated  between  the  skin  and  deep  fascia,  and 
give  a  histor}'  of  long  duration.  The}'  are  usually  presented  as  accidental 
findings,  and  a  diagnosis  is  asked  in  order  to  satisfy  curiosity.     Some- 


672 


TUMORS  OF  THE   UPPER  EXTREMITIES 


Fig.  491 


times  lipomas  develop  from  the  deeper  tissue,  in  which  case  they  present 
a  bulging  of  the  deep  fascia,  are  not  freely  movable,  and  are  not  sharply 
defined.     The  superficial  multiple  tumors  usually  attain  a  certain  size 

and  remain  stationary,  while  the  deeper  ones 
tend  to  progressive  enlargement;  the  latter 
are,  however,  among  the  rarer  tumors  of 
the  arm,  a  pomt  of  marked  contrast  between 
this  region  and  the  thigh  and  leg.  The 
multiple  type  may  be  neglected.  The  soli- 
tary deep  lipomas  tend  to  progressive  en- 
largement and  are  best  removed. 

Fibromas. — Multiple  fibromas  are  fre- 
quently encountered  upon  the  arm.  They 
are  generally  associated  with  some  perver- 
sion of  the  cutaneous  nerves;  which  in  fact 
is  believed  to  be  responsible  for  their  de- 
velopment. They  remain  small,  round, 
movable  subcutaneous  tumors  of  little  or 
no  clinical  importance.  Fibromas  of  larger 
size  may  be  observed,  which  tend  to  pro- 
trude from  the  skin,  forming  sessile  or 
pedunculated  masses.  They  are  rare  and 
are  difficult  to  differentiate  from  sarcomas, 
even  microscopically. 

Neuromas. — These  tumors  are  occasion- 
ally found  in  the  course  of  the  large  nerve 
trunks.  They  are  distinguished  from  other 
tumors  in  these  regions  by  the  fact  that 
they  are  movable  laterally,  but  not  in  the 
Multiple  lipoma  of  the  forearm,     direction  of  the  long  axis  of  the  limb.   They 

should  be  unmolested  if  possible,  since  their 
removal  destroys  the  integrity  of  the  nerve,  the  tumor  being  usually 
of  such  size  that  a  reunion  of  the  nerve  will  be  impossible. 

Rare  Forms  of  Tumors. — Tumors  common  to  the  skin  elsewhere  are 
found  in  this  region,  particularly  angiomas,  papillomas,  and  melanomas, 
the  last  named  not  rarely.  They  present  no  special  characteristics  in 
this  region  save  that  the  last  named  should  always  be  remembered  as 
the  possible  cause  of  an  obscure  axillary  tumor. 


TUMORS    OF   THE   HAND 

The  lower  forearm,  wrist,  and  hand  are  the  seat  of  a  large  number 
of  tumors  which  require  special  consideration  because  of  the  modifica- 


ri  MORS  or  THE  ii.i\h 


(•.;:{ 


nOns   tlu\    picsriit   m   rhis   ic<!,i()ii.      Impoitimt    timiois  from   rlu-  tliim;il 
vitwpoiiu  iiif  rtlan\'cl\'  tcvv. 

Sarcomas.  I  lu-  lowi  r  fon-arni  is  siihjfcr  to  the  same  t\  pe  of  sarcoma 
as  the  up|Hi  portion,  hut  th(.\  oicur  with  less  frequcnc)'.  Sarcoma  ol 
thi-  wiisr  ami  hoius  ot  the  hand  are  sometimes  ohsirsid 

Fig.  492 


TSrtt  iJaiiffj, 


Giant-celled  sarcoma  of  the  tendon  sheath. 


Sarcoma  of  the  hand  and  fingers  may  be  considered  as  involving  the 
skin,  the  tendons,  the  tendon  sheath,  and  the  periosteum  and  bone. 
Those  of  the  skin  do  not  differ  from  those  found  in  this  situation  else- 
where. The}'  frequently  start  from  nevi  and,  as  a  rule,  tend  to  extend 
rapidly  and  to  invade  other  parts,  particularly  the  lymph  glands,  and 
frequently  ulcerate.  The  melanotic  t\pe  is  particularly-  liable  to  rapid 
extension  and  ulceration.  A  peculiar  vascular  t3pe  of  the  latter  has 
43 


674  TUMORS  OF  THE  UPPER  EXTREMITIES 

been  noted  as  beginning  in  the  nail  bed.  About  the  tendons  of  the  hand 
diffuse  sarcomas  are  sometimes  found  which  tend  to  follow  the  sheaths, 
but  may  be  circumscribed.  They  are  characterized  by  persistent  recur- 
rence and  by  a  disposition  to  involve  early  the  axillary  lymph  glands 
and  to  form  general  bodily  metastases.  They  are  slow  growing,  at 
first  painless,  but  later  become  painful.  Because  of  their  clinical 
peculiarities  it  is  difficult  to  differentiate  them  from  inflammatory 
affections,  particularly  from  tuberculosis.  In  striking  contrast  to  these 
tumors  are  giant-celled  sarcoma  (Fig.  492)  which  grow  out  from  the 
tendon  sheaths  of  the  fingers.  In  structure  they  are  fibrosarcomatous, 
containing  many  giant  cells  and  thick-walled  vessels.  In  structure 
and  clinical  course  they  resemble  very  closely  the  epulides.  They  are 
found  constantly  on  the  flexor  side  of  the  fingers,  and  form  hard  globular 
tumors  which  move  quite  freely  in  all  directions  on  account  of  their 
attachment  to  the  tendon  sheath  by  a  rather  small  pedicle.  Their  growth 
is  very  slow,  requiring  a  number  of  years  to  reach  the  size  of  a  hazelnut 
or  hickory-nut,  but  they  tend  to  metastasize  early. 

The  bone  occasionally  is  the  point  of  origin  of  giant-celled  sarcomas 
of  the  same  structure  and  clinical  character  as  those  originating  from 
the  tendon  sheath  just  described.  Small  round  periosteal  or  endosteal 
sarcomas  are  sometimes  observed  which  lead  to  rapid  invasion  of  the 
surrounding  tissue  and  to  the  formation  of  metastasis. 

Diagnosis. — Skin  sarcomas  develop  usually  from  a  mole,  and  manifest 
their  first  activity  by  increased  vascularity  with  the  formation  of  new 
nodules  about  the  periphery  and  later  by  ulceration  and  metastatic 
formation.  In  the  absence  of  these  signs  it  is  often  difficult  to  determine 
if  the  malignant  stage  has  been  reached  or  not.  The  slowly  growing 
tendon  sheath  sarcomas  form  rounded  nodules  free  from  the  skin  with 
deep  attachments.  They  may  be  confused  with  traumatic  cysts  and 
with  foreign  body  fibromas,  and  their  exact  nature  may  not  be  determined 
until  they  are  exposed  at  operation.  The  bone  sarcomas  occurring  may 
simulate  enlargements  due  to  tuberculosis  and  sj^philis.  The  latter 
affection  occurs  in  young  persons,  and  sarcomas  occurring  at  this  age 
are  extremely  hard  to  identify,  but  valuable  evidence  is  obtained  by  the 
specific  tests  for  syphilis. 

Treatment. — Skin  sarcomas  when  occurring  on  one  of  the  digits  are 
best  treated  by  amputation.  When  on  the  dorsum  and  palm,  wide 
excision  will  produce  as  good  result  as  amputation.  The  localized  tendon 
sheath  sarcomas  are  cured  by  local  excision.  Myeloid  sarcomas  of  the 
bone  may  be  treated  by  local  excision,  but  when  on  one  of  the  digits 
the  most  satisfactory  means  is  amputation.  The  infiltrating  periosteal 
type  recurs  in  spite  of  amputation. 


riMfjRs  or  rill:  irixn 


Carcinoma.  I  In-  most  imiior- 
r;iiu  ruinoi  ot  tin-  IkiiuI  is  carci- 
iioiiia,  both  Incause  it  is  trcciucnt 
and  bt'caiisf  of  tin-  (lirticiilr\'  in 
diagnosis.  I  wo  t\  pes  nia\  he 
distinguislu'd,  rhc  ulctrarinii  ami 
the  siihdermal. 

I'he  ulceratini:;  type  (I'l^:;.  493J 
usually  lH'<i;ins  on  a  preexisting 
wart  or  a  seborrheic  patch. 
The  changes  are  similar  to  those 
occurring  in  similar  lesions  in 
the  face  or  lip,  a  gradual  inHl- 
tration  about  the  base  which, 
gradually  extending,  leads  to 
ulceration.  This  ulcer  as  it  pro- 
ceeds shows  typically  the  carci- 
nomatous changes,  the  indurated 
ragged  edge  often  showing  the 
cancer  plugs.  Instead  of  ulcer- 
ation a  fungoid  mass  may  form 
in  some  parts  of  the  tumor  (Fig. 
494),  or  the  lesion  may  be  fungi- 


ble. 491 


Ulcerating  carcinoma  of  the  hand. 


Fic.  494 


Carcinoma  of  the  hand,  parti}'  fungoid. 


676 


TUMORS  OF   THE   UPPER  EXTREMITIES 
Fig.  495 


Fungiform  carcinoma  of  the  hand. 


Fig.  496 


form  from  the  beginning  (Fig.  495). 
Sometimes  there  is  a  disposition  to 
heal  in  some  areas  of  the  tumor  while 
It  extends  at  other  regions  (Fig.  496). 
The  subdermal  type  begins  by  pro- 
liferation of  the  deeper  layers  while 
the  surface  remains  intact  (Figs.  497 
and  498),  but  shows  reddening,  a  glis- 
tening edematous  swelling,  and  con- 
stant exfoliation  of  the  superficial 
spaces  closely  simulating  benign 
cystic  epithelioma.  The  cells  are 
often  large  and  irregular,  and  may 
retain  their  prickles  notwithstanding 
rapid  proliferation.  Degenerated  cell 
types  and  inclusion  forms  are  present 
in  great  profusion.  The  chief  char- 
Carcinoma  of  hand.  The  centre  is  ^cteristic  is  the  disposition  of  these 
heahng,  while  it  is  extending  at  the  cell  masses  and  columns  to  extend 
periphery.  widely  subdermically  before  ulceration 


Fk;.  4V7 

■ 

^ 

^^^^^^^^^^H 

^^^^^^^^H 
^^^^^^^^^H 

^^^^^^B 
' 

V  ^ ' 

t 

A 

^   1 

^^^^^v 

^^^^^1 

^^^B 

Li 

!■ 

Beginning  epithelioma  of  the  hand. 


Fig.  498 


Subdermal  carcinoma  of  the  hand. 


678 


TUMORS  OF  THE   UPPER  EXTREMITIES 


and  far  beyond  the  edge  of  the  ulcer  after  the  epidermal  surface  finalh* 
is  destroyed. 

Diagnosis. — Because  of  the  dense  border  and  dirt}''  ulcer  base  the 
ulcerating  type  is  easy  of  diagnosis.  The  differentiation  must  be  made 
from  tuberculosis  and  mycotic  dermatitis.  The  former  is  rare,  the 
ulcers  smoother,  softer,  and  often  undermined.  Mycotic  dermatitis 
forms  a  softer  wall  which  is  often  bluish,  and  cancer  plugs  are  lacking. 
The  subdermal  type  usually  has  existed  for  one  to  four  j^ears  before 
the  surgeon  is  consulted.  The  lack  of  ulceration  makes  it  impossible 
to  appreciate  the  density  of  the  tumor,  and  because  the  actual  tumor 
mass  does  not  reach  the  surface  cancer  plugs  are  not  seen.  It  resembles 
tinea  and  mycotic  dermatitis  fFig.  499). 

Fig.  499 


Mycotic  dermatitis. 


Treatment. — Wide  excision  is  required,  and  if  situated  on  one  border 
of  the  hand  or  finger  amputation  of  the  affected  area  may  be  under- 
taken. They  tend  to  late  metastasis,  and  conservative  measures  are 
warranted.  A  wide  margin  of  excision  must  be  made  and,  particularl}^ 
in  the  subdermic  type,  the  excision  must  go  very  wide  of  the  apparent 
tumor  margin.  Skin  grafting  will  usually  be  required  to  fill  in  the  space. 
If  the  attempt  is  made  to  preserve  enough  skin  to  close  the  wound,  too 
little  tissue  will  almost  surely  be  sacrificed.  These  carcinomas  often 
occur  in  old  and  decrepit  individuals  beyond  the  j^ears  of  usefulness, 
and  many  surgeons  prefer  to  amputate  in  the  forearm,  well  above  the 
lesion,  rather  than  go  to  the  annoyance  of  local  excision  and  its  trouble- 


TCMOks  or  THE  ii.im)  (17<» 

sonu-  ;itrii-t ii;itnunr.  After  the  ttiulons  li;i\i-  htcoim-  iiuoixcd  ;ini|)iita- 
t  loii  IS  rlu-  oiih    n-t-oiii  sc. 

Angioma.  \ttii  \\\v  hui-,  rlu-  h;iiul  ;iiul  wrist  form  the  most  common 
seat  ot  hlooclx  I  ssci  iiimois.  \e\iis  is  particiilail)'  tVeciuent,  and  small 
|Hiliiiuiilaticl  (.axcinoiis  rumors  are  sometimes  seen.  I  he  arteiies  m 
this  re«:;ion  sometimes  form  racemose  aneurysms.  They  are  mtre(|uenr 
tumors,  hut  of  importance  when  encountered. 

Lipomas.  Iluse  rumors  are  not  freciuent  ahout  rlu-  hand;  rhey 
occur  in  rlu-  rlu-nar  or  hypothenar  eminences  or  in  the  palm,  where  the\' 
ma\'  he  located  helow  or  above  the  palmar  fascia.  I^ecause  of  the 
nature  of  the  tissue  from  which  they  develop,  they  do  not  present  the 
mobilir\  aiul  lobulation  common  to  these  tunu)is  m  other  situations. 
When  the\'  grow  from  the  tendon  sheaths  the\'  produce  spindle-formed 
enlargements  immovable  upon  the  tissue  from  which  the\'  develop. 

Fibromas.  -These  tumors  may  arise  in  the  skin,  the  tendon  sheaths, 
or  the  periosteum.  Those  derived  from  the  skin  are  small,  circum- 
scribed, dense,  globular  tumors,  situated  immediately  below  the  skin 
and  adherent  to  it.  Fibromas  of  tendons  or  the  tendon  sheaths  are  more 
common.  They  run  a  painless  course  and  cause  disturbance  only  by 
interference  with  the  function  of  the  tendon.  The}'  produce  a  "jerking 
tendon."  They  move  with  the  tendon  to  which  they  are  attached.  The 
periosteum  is  onl}'  ver}'  rarely  the  point  of  origin  of  fibroma.  In  some 
of  the  cases  reported  they  have  been  associated  with  a  cartilaginous 
formation. 

Those  fibromas  which  go  out  from  the  skin  are  attached  to  it,  but 
are  freel}'  movable  on  the  underlying  tissue.  The  skin  covering  them 
shows  no  trophic  changes,  nor  are  there  enlarged  bloodvessels.  Those 
going  from  the  tendon  sheaths  are  movable  in  a  lateral  but  not  in  a 
longitudinal  direction;  they  move,  however,  with  the  fingers  and  are 
frequently  associated  with  jerking  of  the  finger. 

Diagnosis. — Fibromas  must  be  differentiated  from  lipomas,  sarcomas, 
ganglia,  and  epithelial  cysts.  Lipomas  are  soft,  semifluctuating,  and 
may  be  lobulated.  Ganglia  are  frequently  dense,  smooth,  and  immov- 
able, and  are  usually  situated  to  one  side  rather  than  over  the  tendon 
sheath.  Lipomas  are  usualh'  on  the  fle.xor  surface  and  frequenth" 
give  on  palpation  a  crackling  sound  like  the  crushing  of  a  snowball. 
On  the  finger  lipomas  are  much  less  frequent  than  the  fibromas,  but 
in  the  hollow  of  the  hand  lipomas  are  much  more  common  and  may 
resemble  forms  of  tuberculosis.  Here  too  the  lobulated  form  is  more 
common,  and  extensive  processes  ma}'  be  formed  about  the  various 
tendons. 

Treatment. — Removal  is  the  only  efficient  treatment.  If  attached  to 
the  sheath  or  tendon   they  must  be  separated.      If  the\'  grow  out  from 


680 


TUMORS  OF  THE   UPPER  EXTREMITIES 


the   tendon   itself  enough   of  the   tendon   should    be   left   to  sustain  its 
continuity. 

Fig.  500 


Adolescent  warts. 
Fig.  501 


Fissured  adolescent  warts. 


Papillomas. — Adolescent  warts  are  familiar  objects  on  the  hands  of 
young  persons.  They  form  nodules  with  smooth  (Fig.  5C0  or  Fig.  501) 
or  fissured  surface.  When  situated  upon  the  dorsum  of  the  hand  their 
importance  is  cosmetic.     When  situated  upon    the  palms  of  the  hands 


r I  MORS  OF   Till-:  II.IM) 


c.si 


tlu'\'  ;iii'  ohm  ;iiin()\  iii<;.  In  this  sii  ii;i  t  loii  ilit\  nKi\  l>c  littK  oi  not  ;tt 
;ill  iU\;ititl  .il)()\t  ilu-  siiihuc  ot  the  siii  roiiiulm^  skill.  I  lu-\'  iiki\'  he 
\cr\  pwintul  to  pitssuii-  ;iiul  may  iiuapacitatc  rlu-  pariiiu  to  a  ln^li 
clt'^nc.       I  luif  IS  no  sliaip  cli\ulinti  line  l>ct\S(cn  this  r\pr  and  corns. 

In  ailolisciiiis  tile  pi  olili  I  a  ti(l  cpii  Ik  limn  t-xists  vsitlioiit  intimate 
association  witii  the  sm  loiiiulmL:,  epidermis,  (htteiiiifi,  in  this  respect  from 
the  papillomas  of  atUanccil  years  in  which  the  epithelium  is  an  intef!;ral 
part  of  the  epidermis.      (See    lumors  of  the  I'acei. 

Warts  when  occurnn;:;  sin<ily  or  upon  the  |)almar  siirtace  and  those 
occurring  late  m  lite  are  best  remo\  eel  h\  deep  excision.  In  rlu  multiple 
warts    of      adolescents      milder 

methods  are  preferable.    Caustic  I"  "<;  SC2 

applications  such  as  a  saturated 
solution  of  salicylic  acid  in  alco- 
hol or  collodion,  strong  solutions 
of  caustic  potash  or  nitric  acid, 
are  commonl\-  employed.  Ihe 
wearing  of  gloves  constantl}' 
ma}'  cause  them  to  disappear. 
Enveloping  the  hand  or  finger 
with  adhesive  plaster  for  some 
weeks  often  causes  them  to  dis- 
appear. 

Rare  Tumors. —  Lymphangio- 
mas.— C3'Stic  lymphangiomas  of 
the  forearm  are  sometimes  ob- 
served. They  form  a  CASt-like 
enlargement  (Fig.  502)  which  is 
incompressible,  tense,  and  elas- 
tic. The}'  are  more  or  less  en- 
capsulated, but  the  connective 
tissue  about  them  is  often  pro- 
liferated, making  the  attachment 
to  the  nerves  and  vessels  in  the 
region  ver)'  intimate  and  the 
removal  difficult.  Their  slow 
growth,  lobulations,  tense  elastic 

feel,  and  deep  attachment  are  characteristic.  The}"  should  be  earl\' 
removed  before  they  extensively  invade  important  structures.  This 
disposition  to  gradual  invasion  and  the  formation  of  new^  cysts  seem 
to  place  them  midway  between  lymph  c^sts  and  lymphangio-endothe- 
liomas. 


Cystic  l\mphangi()ma  of  forearm  and  hand. 


682 


TUMORS  OF  THE   UPPER  EXTREMITIES 


Granulomas. — Allied  with  papillomas  numerous  lesions  traumatic  in 
origin  are  observed.  Simple  granulomas  from  chronic  irritation  may 
occur  as  a  subungual  infection  (Fig.  503).  Epithelial  irritation  may 
lead  to  extensive  local  hypertrophy  (Fig.  504). 

Fig.  503 


Granuloma  of  the  finger  from  infection  about  a  nail  bed. 
Fig.  504 


Epithelial  papilloma  resulting  from  a  burn  from  match  head. 
Fig.  505 


Botr\-omycosis  of  the  finger  resulting  from  a  calf  bite. 

Botryomycosis    fFig.    505). — This    is    most    often    located    upon    the 
fingers.     They  are  fungiform  or  pedunculated  tumors,  usuall}'  soft  and 


ri  MORS  or  rill:  irixn 


(is;^ 


ot  slow  i;i()\\tli,  .iiul  iIrv  soon  hccoim-  srwtioiiai  \  .  I  1k\  should  be 
fxcisril. 

Ganglia.  riusc  ;iif  sinall  cystic  tuniois  which  ^o  out  from  the  tenclt)n 
sluarhs  ami  an  tilled  with  clcai'  Huul.  I  hey  usually  come  from  over- 
r\i  rtioii.  1  In  \  iiia\  In-  drricrccl  hy  the  Ultimate  association  with  the 
ti  luloii.  m(i\iii^  to  and  fio  when  the  fingers  are  flexed  and  extended. 
I'aui  ottin  follows  pi()lon<;cd  movements  of  the  tendons.  The  older 
treatments  of  rupture  of  the  cyst  by  striking  it  a  sharp  blow  and  sub- 
cutaneous innicture  ha\e  now  generally  given  way  to  excision  ot  the  sac. 

Tuberculous  Synovitis.  Tuberculosis  of  the  tendon  sheath  frecjuentl)' 
resembles  a  simple  ganglion.  It  occurs  most  frequently  on  the  tendons 
of  rhc  palm  of  the  hand  and  of  the  flexor  surface  of  the  fingers,  while 
simple  ganglion  occurs  usiialb'  on  the  dorsal  tendons.  I  he  former  is 
usuall)'  single  and  circumscribed  while  the  latter  is  usuall)'  diffuse,  but 
it  may  be  single  and  circumscribed,  in  which  case  it  is  more  definitel}' 
circumscribed  than  the  tuberculous  lesion. 

Fig.  506 


Chondroma  of  first  phalanx  of  the  little  finger. 


Epithelial  Cysts. — The  palm  of  the  hand  is  the  most  frequent  site  of 
the  so-called  traumatic  cysts.  These  tumors  result  from  the  displace- 
ment of  epithelium  by  a  dull  object  which  punctures  the  skin,  carrying 
before  it  a  bit  of  epithelium  which  afterward  develops  into  a  C3'st.  These 
cysts  are  filled  with  the  debris  resulting  from  the  exfoliated  epithelium. 
They  seldom  become  larger  than  a  hazelnut  and  are  permanently  cured 
by  excision. 

Osteomas.  About  the  epiphyseal  lines  bony  or  cartilaginous  growths 
are  occasionally  seen,  sometimes  as  local  expressions  of  a  disease  involv- 
ing many  bones.  The}'  do  not  require  removal,  excepting  from  their 
size.  There  is  a  rare  condition  in  which  about  each  joint  there  is  an 
extensive  osseous  proliferation,  which  ma\'  become  so  large  and  numer- 


684 


TUMORS  OF  THE  UPPER  EXTREMITIES 


ous  that  the  function  of  the  hand  is  entirely  destroyed.  When  hmited 
to  a  few  digits  amputation  may  be  done.  When  all  the  fingers  are 
involved  some  relief  may  be  afforded  by  removing  the  most  offending 
enlargements. 

Fig.  507 


Multiple  ecchondrosis  of  the  fingers. 


Chondroma. — Ecchondroses  about  the  joints  simulating  or  associated 
with  the  preceding  may  occur  (Fig.  506).  More  often  a  single  phalanx 
is  involved.  They  form  spindle-form  or  globular  enlargements  (Fig. 
507).  In  such  instances,  amputation  is  the  best  treatment.  When 
numerous,  the  same  plan  may  be  followed  as  with  the  osteomas. 


e'  II  A  PI  K  R    \  I.  I  \ 

TUMORS   Ol-     i'lIK    LOWER    EXTREMITIES 

TUMORS    OF   THE    GROIN 

[uv.  <!;ioin,  like  the  axilla,  is  the  site  of  occasional  primary  tumors  and 
of  frequent  secondary  tumors.  Unlike  the  axillary  space,  it  is  in  addition 
the  seat  of  a  number  of  conditions  which,  while  tumorous,  are  not  neo- 
plastic in  character.  These  are  the  various  hernias  and  lesions  resultmg 
from  tlu-m  and  the  adenopathies  resultmg  from  genital  and  anal  infec- 
tions. These  facts  make  this  region  one  of  the  most  interesting  from 
the  standpoint  of  clinical  oncology. 

Carcinoma. — Epitheliomas  are  practically  the  only  t\"pe  of  primai)' 
carcinomas  found  in  the  groin,  but  the}'  are  very  rare.  Carcinomas  of 
the  deep  parts  are  more  common  and  are  metastatic  in  origin,  usually 
secondary-  to  tumors  of  the  external  genitals  or  anus,  more  rarely  of 
the  extremity.  Usually  the}^  present  the  usual  signs  of  secondary  car- 
cinoma of  the  lymph  glands — at  first,  hard,  discrete  nodules;  later,  hard, 
fused  masses  fixed  to  the  surrounding  tissue. 

Diagnosis. — Primary  carcinomas  do  not  differ  from  similar  growths 
in  other  situations.  Secondary  carcinomas  are  distinguished  by  their 
density-  and  particularly  by  discover}^  of  the  primary-  growth,  which 
is  seldom  a  matter  of  difficulty  if  search  is  made.  When  it  is  located 
wnthin  the  urethra  or  about  the  anus  the  primar}'  tumor  may  be  over- 
looked. 

Treatment. — Primary  carcinomas  may  be  excised  in  the  usual  manner. 
Carcinomas  secondary  to  lesions  of  the  external  genitals  may  be  removed 
with  the  primary-  grow^th,  however,  without  an}'  considerable  prospect 
of  permanent  cure.  When  they  are  secondary'  to  anal  carcinomas  re- 
moval is  useless.  When  a  secondary  growth  appears  some  time  after 
the  removal  of  a  primar\'  genital  carcinoma,  experience  has  shown  that 
removal  rarel\'  is  attended  by  noteworthy  success. 

Sarcoma. — Sarcomas  are  frequentl}'  observed  in  the  groin  which 
prove  to  be  secondai}'  to  tumors  which  have  been  overlooked.  Search 
will  usuall}'  discover  a  melanotic  growth  which  presents  evidence  of 
recent  irritation  (Fig.  508).  This  possibility  should  alw^ays  be  kept 
in   mind  when  a  tumor  of  the  groin  presents  itself.     Such  metastases 


686 


TUMORS  OF  THE  LOWER  EXTREMITIES 


are  usually  globular  masses  which  grow  rapidly  and  early  become  adher- 
ent to  the  underlying  tissue.     Over  them,  however,  the  skin  is  freely 


Fig.  508 


Melanoma  of  thigh.     Nodule  to  left  is  of  recent  development. 

movable  and  is  without  dilated  vessels,  since  the  superficial  fascia  is 
interposed  between  them  and  the  skin.  Later  the  fascia  is  invaded  and 
vascular  dilatation   in   the   skin   occurs;   both   fascia   and   skin   may  be 

destroyed    and    ulceration     result. 
Fig.  509  Primary  sarcomas    are    sometimes 

observed  in  the  groin.  They  de- 
velop from  the  fascia  or,  more 
rarely,  from  the  lymph  glands; 
but  often  the  origin  cannot  be  dis- 
covered, since  by  infiltration  the}^ 
become  attached  to  surrounding 
tissues  and  the  point  of  origin  is 
lost.  Sometimes  they  become  cystic 
to  such  a  degree  that  considerable 
search  is  necessary  before  sarcoma- 
tous areas  within  the  capsule  are 
definitely  established. 

Diagnosis. — Sarcomas,  because  of 

their  rapid  growth,  may  usually  be 

recognized  with  ease;  the  discovery  of  an  irritated  mole  establishes  the 

diagnosis.      Great   enlargement   from   some   genital   irritation   which    is 


Sarcoma  of  the  groin. 


riMORS  <)i  Tin:  C.ROIS 


•  is, 


otrtii  ot  ohsciin-  ()iii;in  m;i\  siimihiti-  siiicoiiKi ;  siali  inlar^tnitnts  are 
(lirtusc-,  spitailiiii;  ()\c-i  tin-  intirr  ^roin,  while  sarcoma  lorirs  a  globular 
rumor  proitirin};  from  rlu-  <iroin  i  I'ij;.  500).  Oftcii,  too,  the  inHammatory 
<!,laiuls  arc-  pamtui  upon  mampularion,  hur  this  need  nor  Im  an\-  means 
he  rlu-  case. 

Ilotltikin's  disease  ma\  In-  primar\  in  rhe  ^roin  (I'if^.  510).  The 
glands  are  well  defined  and  more  movable  than  glands  of  like  size 
secondary   to  mHammator)'   disease  or  to  tumors. 

Fic.  510 


Hodgkin's  disease  primary  in  the  groin. 


Irreducible  omental  hernias  have  been  mistaken  for  sarcomas,  par- 
ticularly when  the\'  are  mflamed  and  necrosis  is  impending.  In  these 
conditions  the  same  cellular  changes  take  place  within  and  about  the 
omentum  that  are  seen  in  intra-abdominal  inflammations,  particularh- 
about  the  cecum.  Their  exact  location  in  the  hernial  canal  and  the 
degree  of  local  reaction  should  differentiate  them  from  sarcoma.  In 
case  of  doubt  the  inguinal  canal  should  be  laid  open  as  the  first  step  of 
the  operation.     The    c\"stic    sarcomas    are   more    fixed,   and    usuallv  a 


688  TUMORS  OF  THE  LOWER  EXTREMITIES 

thickened  wall  distinguishes  them  from  pure  cysts;  they  are  also  more 
common  and  develop  more  rapidh^  The  cysts,  on  the  other  hand,  are 
congenital  or  of  slow  growth,  thin  walled,  and  their  fixit}^  depends  upon 
their  point  of  origin.  The  skin  covering  them  is  unchanged.  The 
lymphatic  cysts  are  fixed  deeply  at  the  normal  location  of  the  vessel 
they  are  associated  with  and  are  incompressible,  while  the  blood  cysts 
are  compressible;  diagnostic  aspiration  may  be  necessary  for  a  differ- 
entiation. 

The  lipomas  when  deeply  seated  may  resemble  sarcoma,  and  though 
slowl}^  growing  there  may  be  a  history  of  apparently  sudden  enlarge- 
ment. A  lipoma,  for  instance,  growing  subfascially,  may  burst  through 
the  fascia  as  a  result  of  injury  or  spontaneously,  and  the  patient  may 
present  the  history  of  a  rapid  development  following  trauma.  The 
evident  capsulation  and  the  uniform  soft  feel  lead  to  a  correct  diagnosis. 
Tumors  from  the  surrounding  bon}"  parts  may  form  projections  into  the 
groin,  but  their  nature  is  evident  from  their  bony  attachment.  Sarcomas 
which  become  attached  to  bone  secondarily  may  sometimes  be  confused 
with  tumors  starting  in  the  bone  itself. 

Treatment. — Sarcomas  when  secondary  to  melanotic  growths  have  a 
prognosis  which  is  equally  bad  whether  removed  or  let  alone.  Primar}' 
sarcomas,  particularly  the  cj^stic  type,  may  be  at  least  temporaril}' 
cured  by  removal.  When  the  vessels  of  the  skin  over  these  tumors  are 
much  dilated,  it  indicates  that  the  surrounding  tissue  is  invaded,  and 
when  the  veins  of  the  thigh  are  prominent  it  is  safe  to  assume  that  they 
indicate  an  obstructed  circulation  of  the  femoral  or  external  iliac  vein 
due  to  invasion;  both  conditions  contraindicate  operation. 

Lipomas. — Lipomas  in  this  region  are  not  uncommon.  The}^  fre- 
quently develop  from  fat  within  one  of  the  hernial  openings,  or  from 
the  subcutaneous  or  subfascial  adipose  tissue.  When  they  develop 
from  the  fascia  they  produce  a  diffuse  swelling,  and  if  the  fascia  ruptures 
at  one  point  a  lobulation  appears  there.  The  tumors  are  soft,  semi- 
fluctuating,  lobulated,  and  of  slow  growth. 

Diagnosis. — Lipomas  which  grow  from  a  hernial  opening  may  be 
indistinguishable  from  an  omental  hernia  except  for  their  disposition 
to  form  globular  masses,  while  omental  hernias,  though  composed  of 
fatty  tissue,  retain  the  form  of  the  canal  within  which  they  lie.  Hernias 
composed  either  of  intestines  or  omentum  are  often  found  beneath 
lipomas  of  the  canal. 

Treatment. — Lipomas  are  easily  removed,  though  when  the}'  send 
prolongations  among  the  vessels  of  the  groin  or  into  a  hernial  opening 
an  extensive  dissection  may  be  required  for  their  removal.  When  in 
the  inguinal  region  the  possibility  of  a  hernial  complication  must  never 
be  overlooked. 


rr.MfjRs  or  riii:  riiu.ii  c.s!) 

Rare  Tumors.  Aiuiii  \  sins  ot  ilu  (tni«)i;il  ;iirir\-  :ne  soiiuriiiies 
ohsfiwtl.  I  lu-  hnioral  ;is  will  ;is  tlu'  loii^  saplunous  \cin  ma\  cause 
tumors  In  tluii  saccular  ililatarioiis.  I.\  nipliatic  dilatations,  c-itlu-r 
acciuinil  or  more  often  conjicmtal,  mav  occur.  \  anous  lymph  ^lantl 
h\pci  t  lojilncs  may  occur  which  c\in  on  microscopic  examination  may 
cause  contusion.  Osteomas  from  the  suiiouiulin^  hone  ma\  he  present 
in    the   uiom. 

Diagnosis.  I  rnilucihK-  heiinas  ma\  resemhie  cysts  on  account  (A 
their  compressihility,  hut  they  give  a  tympanitic  n(;te  on  percussion 
which  is  distinctive.  Interstitial  hernias  are  particularly  confusing, 
and  ohscure  tumors  impinging  on  the  inguinal  canal  should  always  be 
regarded   \\ith   suspicion. 

Treatment.  Cwsts  may  be  excised.  \  enous  tumors  when  involving 
the  saphenous  alone  ma\'  be  ligated,  hut  the  danger  of  thrombosis  of 
a  femoral  vein  should  be  remembered.  Bony  tumors  present  in  this 
region  may  be  removed  with  a  chisel. 


TUMORS    OF    THE    THIGH 

The  upper  end  of  the  thigh  is  the  seat  of  many  superficial  tumors 
that  do  not  differ  from  those  in  other  parts  of  the  bodw  Among  these 
may  be  mentioned  particularly  lipomas,  wens,  and  fibromas.  Carci- 
nomas of  the  skin   in   this  region  are   rare. 

Adenomas. — Adenomas  of  the  sebaceous  glands,  common  in  the 
perineal  region,  are  sometimes  observed  on  the  thigh.  The  cells  char- 
acteristic of  such  glands  may  be  discovered  in  the  periphery  of  the 
tumor,  and  the  duct  may  be  prominent.  Aberrant  mammary  glands 
have  been  reported  in  this  region;  these  adenomas  resemble  nipples  in 
external  form,  but  the  type  of  their  cells  does  not  resemble  those  of  the 
mamma.  The  occurrence  of  aberrant  nipples  in  this  region  is  question- 
able on  embr3'ological  grounds. 

Sarcomas. — Sarcomas  of  the  thigh  are  relatively  frequent  and  usually- 
develop  from   bone  but  may  develop  in  the  soft  parts. 

Varieties. — Sarcoma  of  Bone. — These  are  of  two  t\pes:  (i)  Endosteal 
sarcomas  go  out  from  the  medulla  (Fig.  511),  and  may  comprise  cells 
of  an}-  size  and  form.  They  are  usualh'  found  at  an  epiphysis  (Fig.  512), 
particularh'  at  the  lower  end.  The\^  expand  the  cavity  of  the  bone  until 
a  mere  shell  remains;  the  surrounding  tissue  ma\-  be  rapidly  invaded  and 
spontaneous  fracture  occur.  (2)  Periosteal  sarcomas  are  likewise  seen 
at  the  lower  1  Figs.  513,  514,  and  515)  end  of  the  femur,  but  their  usual 
seat  is  in  the  diaph}sis.  The  cell  form  is  variable,  but  giant-celled  tumors 
are  more  frequent  than  in  the  endosteal  variety.  They  cause  a  spheroid 
44 


690 


TUMORS  OF  THE  LOWER  EXTREMITIES 


Fig.  512 


or  spindle-formed  enlargement  (Fig.  516)  of  the  bone  or,  more  correctly 
speaking,  about  the  bone,  for  it  is  usually  cellular  invasion  of  the  soft 
parts  that  causes  the  enlargement. 

Clinical  Course. — The  rate  of  growth 
is  variable.  Often  large  tumors  are 
formed  in  a  few  months,  but  usually 
six  to  eighteen  months  are  required 
before  a  tumor  of  any  considerable  size 
is  formed;  and  rarely  many  years  pass 
before  the  patient  is  sufficiently  im- 
pressed   with    its    importance     to    seek 

Fig.  511 


Endosteal  sarcoma  of  the  femur. 


Endosteal  sarcoma    of  the  lower 
end  of  the  femur. 


advice.  In  any  case,  the  growth  is  progressive,  usually  painless,  and 
without  evidence  of  local  reaction,  though  rise  of  temperature  and 
leukocytosis  may  occur,  particularly  in  the  more  rapidly  growmg 
types.     A  dull  pain  is    sometimes  present.     Except    in    the    periosteal 


r  I  MORS  or  THE  run. II 


<;i)i 


typt-  111  wIikIi  ;i  I()c;iIi/k1  ^lohulai  tumor  m;i\  he-  lorimd  the  jiiouths 
prodiKc-  ;i  tiisitoiiii  i  nLir^tiiu  in  wirli  dcHnite  outliiu-,  hut  the  sense 
ot  eiuapsuhition  IS  ahsciit.  When  located  near  a  joint  the  spindle 
form  and  the  outhne  ot  the  tumor  may  he  lost  in  the  normal  or  ex- 
aggerated contoui  of  the  joint.  Their  consistency  varies,  but  is 
usually  him,  thouuh  the  very  cellidar  r\  pes  ma\    he  soft. 


:i' 


Periosteal  osteosarcoma  of  the  lower  end  of  the  (einur. 


Sarcomas  of  the  Skin. — These  go  out  especially  from  the  moles. 
Sometimes  the  primary  tumor  is  ver\'  small,  while  metastasis  in  the 
inguinal  hmph  nodes  or  metastatic  deposits  in  other  organs  ma\'  be 
ver}'  extensive.  An  irritated  and  enlarged  nevus  should  always  be 
regarded  as  a  matter  of  importance.  Sarcomas  of  the  muscle  are  of 
frequent  occurrence.  The  vast  majority  of  them  go  out  from  the  fascia 
early  and  ma\'  appear  as  tumors  of  that  structure,  but  more  careful 
examination  will  show  that  their  real  origin  is  much  more  deepi}'  situated. 
Slowh'  growing  sarcomas  are  sometimes  observed  upon  the  upper  part 
of  the  thigh  which   resemble  those  described  on   the  abdomen.     They 


692 


TUMORS  OF  THE  LOWER  EXTREMITIES 


are  sessile  and  the  skin  over  them  is  red  and  thin.     These  tumors  are 
unattached  to  the  fascia  and  move  with  the  skin. 

Myxosarcomas. — These  occur  in  the  thigh  relatively  frequently. 
They  are  soft  and  semifluctuating,  often  definitely  lobulated,  and  often 
grow  with  great  rapidity.  In  many  of  these  tumors  the  larger  part 
is  formed  b}^  pure  myxoid  tissue,  but  a  continued  search  reveals  areas 


Fig.  514 


Section  of  a  periosteal  osteosarcoma.     Bone  trabeculae  invade  the  entire  tumor. 

of  definite  sarcomatous  tissue.  When  microscopic  evidence  of  malig- 
nancy is  lacking  they  show  their  disposition  by  persistent  recurrence, 
and  ultimately  give  definite  evidence  of  malignancy,  either  by  extension, 
infiltration,  or  by  the  formation  of  metastases. 

Diagnosis. —  Tumors  of  the  bone  do  not  differ  from  tumors  elsewhere. 
Bone  sarcomas  are  most  frequentl}^  confused  with  inflammatory  diseases 
of  the  bone,   chiefly  osteomyehtis  and   tuberculosis.      In  osteomyelitis 


riMORs  or  Tin:  riiicii 


C)!!:; 


rluTc  IS  ^»;en(.Tall\  rlu-  hist()i\  ot  an  aiiitt-  atratk,  and  tlu-  iiioNstli  is  so 
slow  that  It  IS  nioii-  apt  to  In-  lonliistd  with  hone  c\  srs  than  \\\x\^  mali^;- 
naiit  distasi'.  I  iilitriulosis  ot  the  shatr  is  ex  r  re  me  I  v  rare;  when  it  aHects 
the  joint  there  is  pain  on  moNenient,  often  earl\'  crepitation  and  muscular 
ati()ph\  .  .A  \arur\  ot  jonit  Usions  of  the  kiu-e  ma\  siniiihite  sarcoma. 
In  joint  lesions  the  point  ofiiiaximum  enlargement  is  at  the  joint  cavit}' 
or  at  the  pi()lonf:;ations  of   the  synovial   memhrane,  while  in   sarcomas 


Periosteal  sarcoma  of  lower  end  of  femur. 


the  point  of  maximum  enlargement  is  above.  The  patellar  prolongation 
of  the  synovial  sac,  when  it  is  the  seat  of  inf^ammator\-  or  lipomatous 
thickening,  may  be  distinguished  by  the  movement  imparted  to  it  by 
flexion  of  the  leg  on  the  thigh.  Sarcoma  does  not  tend  to  invade  the 
joint  cavities.  Sarcomas  of  the  soft  parts  frequently  are  extensions 
from  the  bone;  when  primary  they  tend  to  invade  the  surrounding  tissue, 
but  the  outlines  of  the  tumor  are  always  better  defined  than  in  an  inflam- 
matory  process.      Myositis  ossificans   or  fibrosa   may   be  exceptions   to 


694 


TUMORS  OF  THE  LOWER  EXTREMITIES 


this  rule,  but  are  confined  to  one  muscle  usually.  The  x-rays  may  clear 
up  the  difficulty  by  showing  a  spindle-formed  bone  shadow  within  the 
muscles.  Syphilitic  periostitis  may  form  fusiform  enlargement  of  the 
bone  (Figs.  517  and  518)  which  may  resemble  sarcoma  very  closely. 
History  or  other  evidence  of  syphilis  may  be  obtainable.  The  ;v-ray 
plate  is  very  characteristic;  it  shows  a  lighter  shadow  about  the  bone. 
The  local  infiltration  of  the  syphilitic  process  into  the  soft  parts  may 

Fig.  516 


Giant-celled  periosteal  sarcoma  of  bone. 


form  a  more  or  less  sharply  defined  tumor.  The  onset  is  usually  more 
acute  than  sarcoma,  and  there  is  usually  pain,  most  often  nocturnal, 
and  often  of  great  severity.  Cystic  lymphangioma  of  the  thigh  (Fig.  519) 
may  cause  fusiform  enlargement.  Usually  lobulations  can  be  made  out 
which  are  absent  in  sarcomas. 

Treatment. — No  matter  how  certain  the  diagnosis  of  a  sarcoma  of  the 
thigh  may  be,  an  exploratory  incision  should  be  made  before  amputation 


TCMfJRS  or   '/■///■:    Til  Kill 


695 


1\\  thosi-  who  ilo  nor  siihscnhc-  to  loc;il  opci  ;it  ion.  I'cnosrc-al  sarcoiiuts 
may  sonu-tiiius  In-  niiioMtl  locally;  hut  frequently  the  surroundinji; 
nssiu'  is  unadid  w  hen  the  patient  is  Hrst  seen,  in  which  case  amputation 
aloiu'  n  iiKiiiis.  Sarcomas  of  the  soft  parts  ma\'  sometimes  he  renKJved 
locall\  .  Ihe  locah/cci  tumors  of  the  i)oiu-  ^i\f  the  hest  prospect  of 
permanent  relief  h\  local  excision.  I  nfortunately  these  often  do  not 
come  to  treatment  until  all  bone  is  destroyed,  so  that  when  the  tumor 

Fig.  517 


Syphilitic  periostitis  of  the  temur. 


is  removed  the  continuity  of  the  shaft  is  interrupted.  It  is  probable 
that  a  mere  shell  of  bone  remaining  warrants  conservatism.  Resec- 
tion in  continuity  and  implantation  is  preferable  to  amputation  in 
certain  cases.  The  m3'xosarcomas  must  be  widely  excised.  Even  with 
this,  local  recurrence  and  necessity*  of  ultimate  amputation  ma\'  be 
predicted. 

Neurofibroma. — Neurofibromas  of  the  sciatic  nerve  frequenth'  cause 
confusion  in   diagnosis.      If  thcA'   have   attained  some  size  the\'  appear 


696 


TUMORS  OF   THE  LOWER  EXTREMITIES 


prominently  under  the  surface  as  superficial  tumors.     They  are  usually 
dense  and  move  readily  from  side  to  side,  but  not  in  the  long  axis  of 


Fig.  si8 


Syphilitic  periostitis.     The  thickened  periosteum  is  shown  at  A. 


the  thigh.     These  sciatic  tumors  may    be  attached  to  one  side   of  the 
rve,  or  they  may  infiltrate  it,  causing  a  fusiform  expansion.     They 


ner 


Ti'MORs  or  rill.  Ill  Kill 


(i'.)7 


Fk;.  51V 


wii.-  iiMKilh  (ibiomas,  01  hhiosimomw.s,  ;iiul  wir  not  wiiompiiiiutl  hv 
prolifi  rarioii  ot  n(iii;il  ikiiunts. 

Diagnosis.  I  iiinois  ot  rlu-  iutm-  nia\'  cause-  pain  or  im|Kiirnunt  of 
tiiiurioii.  Init  usualU  luirlur  ot  rlusc-  coniplicarions  is  prtst-iu,  and  rlu- 
tailiin-  to  nio\  I-  m  a  loiimriiclinal  (iiiicrioii  as  (.•ontrasrtd  to  rlu-  latc-ial 
in()hilir\    iiuist  make-  rlu-  cliafiiu)sis. 

Treatment,  it  rlu-  tiitnois  lie-  c-ccc-iirnc  ro  rlu-  rur\'c,  ir  nia\'  be  possible 
ro  leinoNe  rlu-  riinu)r  and  leave  rlu-  iur\e  iinaer.  It  the  tunujr  is  t(jo 
closely  associarcd  witti  rlu-  iu-i\e,  lesec- 
tioii  with  union  may  be  possdile.  It  the 
tunu)!'  is  tibrous,  it  may  be  allowed  to 
remain,  permittinj^  the  patient  to  bear 
the  mcomemence  ot  the  tumor  rather 
than  to  destro\'  the  tuncrion  ot  so  impor- 
ranr  a  nerve. 

Fibroma.  Fibromas  of  rhe  rhi<ih  are 
localized  1  Fig.  520)  or  form  a  part  of 
elephantiatic  processes.  They  form  sott 
lobulated  masses  which  ma}'  hang  in 
folds.  They  resemble  the  neurofibroma- 
tosis often  seen  in  the  temporal  region. 
The  soft,  tiabby,  semisohd  feel  is  char- 
acteristic. When  troublesome,  the  masses 
may  be  excised. 

Chondroma. — Chondromas  about  the 
epiphyseal  lines  are  sometimes  observed; 
they  are  characterized  b}'  their  slow 
growth. 

Bone  Cysts.' — The  femur,  together  with 
the  tibia  and  humerus,  is  the  most  common     Cystic  lymphanuioma  of  the  thigh, 
site  for  bone  c^'sts.     The)'  usually  begin 

before  the  twentieth  year.  They  cause  bone  enlargement,  pain  and  spon- 
taneous fractures.  The  age  of  the  patient  and  slow  growth  together  with 
the  examination  by  the  v-rays  suggests  the  diagnosis  but  the  exploratory 
incision  must  prove  it.  When  the  cavity  is  lined  by  a  fibrous  membrane 
the  diagnosis  is  eas^'  and  when  it  is  absent  the  brownish  contents  and 
the  absence  of  evidence  of  sarcoma  permits  a  diagnosis.  Curettage  is 
the  treatment  in  all  cases. 

Bone  Aneurysms.- — Under  this  heading  cystic  cavities  filled  with 
blood  occurring  in  the  shafts  of  long  bones  have  been  described.      Xot- 


"■  For  a  complete  presentation  of  bone  cysts  see  Bloodgood,  .Ann.  Surg.,  1910,  In,  145. 
^  Gaylord,  Ann.  Surg.,  1903,  xxxvii,  834. 


698 


TUMORS  OF  THE  LOWER  EXTREMITIES 


withstanding  their  name  they  have  nothing  to  do  with  saccular  dilata- 
tions of  bloodvessels,  but  on  the  contrary  are  due  to  degeneration  of 
some  form  of  sarcoma.  There  is  an  absence  of  the  fibrous  hning  often 
found  in  bone  cysts  and  the  contents  is  usually  clotted  or  partly  organ- 

FiG.  520 


Fibroma  of  the  thigh. 


ized  blood.  They  occur  later  in  life  than  blood  cysts  and  are  often  more 
rapid  in  their  development.  They  often  break  through  the  bony  wall 
and  infiltrate  the  surrounding  tissue.  Because  of  this  tendency  ampu- 
tation is  demanded. 


71  Moks  or  THE  riiicii 


099 


Osteomas.  Honv  uiowths,  (.Nosroscs  'Kij^.  :;2i)  or  osteomas  are  not 
intreiiutiu  iii  rlu-  lower  end  of  tin  ("crmii.  'riie\  ma\  he  the  result  of 
injiir\-  oi  ma\  oeeiir  spontaneously,  most  often  as  a  congenital  dis- 
turbance. \\  hen  hroaci  h()n\-  tumors  osseous  in  character  develop 
upon  riu'  tinuir,  malif^nancy  must  he  suspected.  In  these  often  sar- 
coma cells  are  (.iemonstratetl  with  diificulty,  \et  metastases  often  occur. 
1  he  rate  ot  growth  is  usually  a  safe  clinical  criterion.  1'he  exostoses 
and  osteomas  when  judunculated  ma\'  be  easil\-  removed  with  a  chisel. 


Fig.  521 


Fic;.  5: 


■S.rxovye^tna^Ti   1^10. 

Exostosis  of  the  femur. 


Lipoma  of  thigh  infiltratmg  the  adductor 
longus  muscle. 


Lipoma. — These  tumors  are  frequenth'  observed  in  the  thigh  (Figs. 
522  and  523).  When  superficial  they  do  not  differ  from  similar  tumors 
elsew^here.  Less  easih'  diagnosticated  are  the  deeper  ones  which  go  out 
from  the  intermuscular  septa  and  in  their  growth  carry  the  muscle  before 
them  and  may  mvade  it  m  various  directions.  They  are  soft  and  semi- 
fluctuating,  but  may  be  fixed  b\'  their  numerous  ramifications  about  the 
denser  structures  of  the  thigh. 

Diagnosis. — Sarcomas  of  the  soft  parts  resemble  them  phA'sically, 
but  usually  grow  very  rapidly  and  with  pain.     The  common  sarcomas 


700 


TUMORS  OF   THE  LOWER  EXTREMITIES 


of  this  region  are  periosteal  in  origin  and  are  characterized  b}'  fixity 
to  the  bone.  Lipomas  which  grow  beneath  the  fascia  sometimes  pene- 
trate it  and  project  through  the  opening  when  the  contracting  muscle 
presses  upon  them.  In  such  instances  the  resemblance  to  muscle  hernias 
is  very  close,  especially  when  the  lipoma  first  makes  its  appearance 
during  muscular  effort. 

Treatment. — Lipomas  of  the  thigh  should  be  removed  when  discovered, 
for  when  allowed  to  remain  they  tend  to  rapid  development.  Lipomas 
when  diffuse  require  care  in  removal,  lest  some  of  the  tumor  be  over- 
looked. 

Fic.  ^23 


Subcutaneous  lipoma  of  the  thigh. 


TUMORS   OF   THE   KNEE   AND   POPLITEAL   SPACE 


The  knee  and  the  region  about  is  the  seat  of  a  limited  number  of 
varieties  of  tumors,  but  their  determination  is  much  complicated  by 
inflammatory  affections  of  the  joint,  so  that  a  discussion  of  knee  tumors 
is  chiefly  a  discussion  of  differentiation. 


riMfJks  or  riii:  k\ /■:/■:  .i\i)  I'oi'i.iri:.!!.  sr.icE 


7(11 


Sarcoma.  I'lu-  pio.xmKil  ciul  of  ilir  til)i;i  ;,n(l  i|,,-  dist;,!  cxtiiMiin- 
ot  tlu'  kimii  ;m-  xcvy  common  scats  of"  hone  saicoma.  Ihc  ^ianr- 
ccIIkI  t\  pc  forms  a  circiimsci  ilxd  tumor  cither  within  (  V\\i.  524)  or  with- 
out, or  ma\  perforate  the  hone  (Fig.  525).  The  small  round-celled 
t\  pe  moic  commonl\  lu«ims  m  tin-  periosteum  and  often  soon  penetrates 
the  soft  parts  (V\^.  526).  Saicomas  which  i)tM.ni  m  the  siihciitantoiis 
tissue  and  form  fun<iiform  masses  are  seen  in  the  lej,r,  hut  less  often  than 
ahout  tile  trunk  •  hi-.  ^27).  The  filniia  is  much  less  often  the  seat  of 
sarcoma.      I  hi-  peiiosteal  sarcomas  arc-  more  common  than  the  endosteal. 


Giant-celled  sarcoma  of  the  tibia. 


Clinical  Course,  l^he  small-celled  t\pe  may  grow  rapidlw  so  that 
within  a  few  months  a  large  tumor  has  developed.  On  the  other  hand, 
the  giant-celled  type  ma^'  develop  slowly,  several  years  being  required  to 
produce  a  tumor  demanding  the  attention  of  the  patient.  The  e.xpan- 
sion  of  the  bone  or  the  invasion  about  it  produces  an  enlargement 
which   IS  continuous  with    the  natural   enlargement  of  the  joint.     The 


702 


TUMORS  OF   THE  LOWER  EXTREMITIES 


growth  of  the  tumor  is  away  from  the  joint,  so  that  even  with  large 
tumors  the  articular  surface  is  spared.  Only  rarely  is  the  joint  cavity 
invaded.  In  the  small-celled  type  the  entire  tissue  of  the  joint  may 
become  infiltrated. 

Fig.  525 


Giant-celled  sarcoma  of  the  head  of  the  tibia. 


Diagnosis. — When  a  tumor  is  demonstrated  in  this  region  springing 
from  within  or  about  the  joint,  the  problem  of  diagnosis  lies  between 
sarcoma  and  jomt  affections. 

The  differentiation  is  simple  if  it  is  remembered  that  in  sarcoma 
the  point  of  maximum  enlargement  is  at  the  largest  part  of  the  bone 
above  or  below  the  joint,  while  the  joint  itself  is  spared.  In  inflammatory 
affections,  on  the  other  hand,  the  largest  part  of  the  tumor  is  at  the 
line  of  the  joint  (Figs.  528,  529,  and  530),  and  that  the  joint  itself  is 
affected;  which  is  manifest  by  a  crepitus  from  the  rubbing  of  eroded 


Fio.  526 


Round-celled  periosteal  sarcoma. 
Fig.  527 


Sarcoma  of  the  ankle. 


Fig.  528 


Gonorrheal  synovitis. 


77  i/oA'.s  or  Till-:  km:!',    im)  i'oi'i.rn.n.  sr.ici: 


,  ( ).') 


smtacts  .iiul  l>\  I  he  iiu-ic'ast-  of  tliiul.  The  most  tomiiioii  aHcctions  of" 
rlu-  joint  an'  I  iiluniilosis  in  the  \()iini;,  iioiiorilua  in  the  \'oung  adulr, 
rheumatism  m  (In  muKllc-a^cd,  and  aitliiitis  or  tabes  in  those  of 
adxaiuid  \(ais.  Mu-  po.ssd)iht\  ot  the  cxistciu-c  of  these  makes  it 
easy  ro  maishal  \\\v  tacts  siihstant la t in^,  thini  if  aiu  are  present.  In 
those    affecrions    which    are    characreii/ed    h\-    an    increase    of   fluid    rlie 

Fig.  S30 


Gonorrheal  s\no\itis. 


differentiation  is  at  once  apparent.  It  is  only  when  the\-  are  attended 
by  thickening  of  the  bone  or  of  the  synovial  sac  that  difHcult\-  can  arise 
(Fig.  351  ).  In  the  shaft  osteomyelitis  may  cause  extensive  tumefaction 
(Fig.  532,  and  ^33  )  resembling  sarcoma,  and  syphilitic  periostitis  mav  also 
simulate  sarcoma.  The  differentiation  is  given  under  Tumors  of  the 
Thigh. 
45 


706 


TUMORS  OF  THE  LOWER  EXTREMITIES 


Lipomas. — Fatty  tumors  may  develop  within  the  joint  cavity  and 
about  the  capsule  as  an  hypertrophy  of  the  perisynovial  fat.  Aside 
from  their  bulk,  they  cause  no  symptoms.  The  distention  may  be 
uniform,  but  is  soft  and  boggy,  and  aspiration  yields  no  fluid.  Lipomas 
may  develop  in  the  popliteal  space  and  cause  a  bulging  in  the  ham- 
string quadrangle.  They  have  the  soft,  boggy,  semifluctuating  feel 
common  to  such  tumors. 


Fig.  531 


Fig.  532 


Villous  arthritis. 


Local  osteomyelitis  of  leg. 


Tumors  of  Popliteal  Space.— The  popliteal  space  (Fig.  534)  is  the  seat 
of  a  type  of  fibrosarcoma  poor  in  cells  and  as  dense  as  a  pure  fibroma, 
which  it  resembles  histologically;  but  it  persists  in  local  recurrence,  and 
with  each  recurrence  takes  on  a  more  mahgnant  structure.  It  resembles 
in  cHnical  course  the  endotheliomas,  but  there  is  nothing  in  the  struc- 


TUMORS  OF    rill:    KSEI'    .l\l)   I'Ol' I.I  IK.1 1.   SI'.ICI: 


707 


ruii'  to  \\;iii;iiit  such  il;issitu:ii  ion.      It  is  iiuonipli  i  rl\   ciuiiiisiil:!  ted  ;in(l 
(lot-s  not   iiu)\i-  hiclv   upon   the  iiiulci  l\  iiijj,  tissiic. 

Bloodvessel  Tumors. — Aneurysms  when  present  aic-  usually  easily 
enou^ih  tlisnn^uished.  Venous  dilatarion  somcriiiics  forms  promi- 
nences which  may  he  conlused  with  pulsating  tuniois  wlicii  Ivmg  upon 
the  hl()od\essels. 

Fk;.  533 


X-ray  photograph  of  localied  osteomyelitis  of  the  tibia. 


Neurofibromas. — The  nerves  in  this  region  form  tumors  less  frequently 
than  those  higher  up.  The}^  are  globular  or  spindle-formed,  dense  tumors, 
which  move  with  relative  freedom  laterally,  but  not  in  the  long  axis  of 
the  leg. 

Cystic  Tumors. — The  prepatellar  bursa  is  a  frequent  seat  of  enlarge- 
ment, and  other  synovial  bursa  in  the  region  of  the  knee  sometimes 
enlarge,  forming  globular,  dense,  elastic  fluctuating  tumors.  Their 
topography  usually  makes  their  recognition  eas}'. 

Exostoses,  Osteomas,  etc. — Cartilaginous  or  bony  outgrowths  are  fre- 
quent about  the  knee  (Figs.  535  and  536).  The  exostoses  particularly 
are  frequent,  and  from  their  size  ma}*  cause  inconvenience.     Osteomas 


708 


TUMORS  OF   THE  LOWER  EXTREMITIES 


are  less  commonly  disposed  to  malignanc}^  here  than  in  the  femur^  and 
are  usuall}^  the  result  of  developmental  disorders. 


Fig.  534 


Exostosis  of  the  tibia. 
Fig.  536 


Fibrosarcoma  of  the  popHteal  space 


Exostosis  of  the  tibia. 


TUMORS    OF   THE    CALF 

The  superficial  tissues  of  the  calf  may  be  the  seat  of  tumors  which 
are  common  to  such  structures  elsewhere.     On  account  of  the  frequency 


rr.Moks  or  the  c  ii.r  To'i 

ot  ulcHTs  m  this  I ciiioii,  skin  laicmomas  an-  iiioic  lonimon  than  iii  other 
parrs  ot  the-  Icl\  although  they  form  oiil\  a  small  pr()|)orrion  ot  rhe 
ulccratnt.'  i^iotcsscs  ot  rhe  k-jj;.  \\  lun  chronic  ulcers  luidcr^o  nialij;naiit 
chantit*  the  celiacs  hcconu-  nioic  dense  and  cancer  plu^s  nia\'  otten  he 
demonstrated.  In  man\'  cases  onl\'  ont-  j^ortion  ot  the  ciiciimterence 
becomes  carcmoiiiatous.  Superticial  tihronias  and  lipomas  often  occur, 
but  less  tre(|iuntl\'  than  m  rhe  forearm.  Adenomas  of  rhe  skin  ^Iands 
are   rare   tumors. 

Sarcomas.  I  he  most  nnporranr  tumors  ot  the  calt  are  the  saicomas. 
They  may,  as  in  the  thigh,  develop  trom  the  soft  parts,  the  endosteum, 
or  the  periosteum,  and  all  cellular  types  have  been  observed.  The 
slowly  growing  myeloid  sarcomas  are  most  common  in  the  upper  portion, 
where  the\  form  a  more  or  less  prominent,  well-defined  tumor.  \\  hen 
endosteal  m  origin,  sarcomas  ma\'  carr}'  a  shell  of  bene  upon  their  sur- 
face, which  when  palpated  may  give  a  crackling  sound.  1  he  periosteal 
type  is  frequent  in  the  lower  third  ot  the  bone.  These  tumors  are  usualh' 
rapid  in  growth  and  spread  diffusely  after  invading  and  destroying  the 
skin,  and  sometimes  an  ulcerating  mass  is  protruded.  Tumors  which 
develop  primarily  in  the  soft  parts  are  rare.  Lsually  they  infiltrate 
the  surrounding  tissue  so  extensively  that  their  independence  from  the 
periosteum  can  be  demonstrated  onl\'  by  careful  dissection. 

Diagnosis. — Chronic  osteomyelitis  with  much  production  of  new  bone 
has  been  mistaken  for  sarcoma.  The  slowness  of  the  process,  the  fre- 
quent persistence  of  a  sinus,  and  the  extent  of  bone  affected  should 
make  the  differentiation  easy.  In  extremely  chronic  cases  the  area 
involved  may  be  small  and  a  local  tumefaction  be  produced.  These 
because  of  their  great  chronicity  resemble  more  closely  osteomas  or 
bone  cysts.  Exostoses  and  ecchondroses  are  usually  of  such  slow  growth 
and  are  so  definitely  limited  that  confusion  with  sarcoma  is  not  probable. 
Angiomas  and  bone  cysts  may  be  confused  with  sarcoma.  Often  a 
positive  diagnosis  cannot  be  made  until  the  bone  is  opened.  Tuber- 
culosis of  the  ankle  can  be  distinguished  by  the  pain,  the  limitation  of 
motion,  and  the  involvement  of  the  joint  surface.  Charcot's  joint  is 
especially  likeh'  to  be  mistaken  for  sarcoma  because  of  its  painlessness 
and  because  sarcoma  in  this  region  is  very  likely  to  invade  the  articular 
surface.  In  a  suspicious  case  evidence  of  tabes  must  be  sought,  and 
an  .v-ra\'  plate  may  give  valuable  aid  in  diagnosis. 

Treatment. — The  upper  portion  of  the  tibia  gives  the  most  frequent 
opportunity  for  conservative  operation  of  sarcomas.  In  their  removal 
a  rim  of  bone  should  be  chiselled  awaA'.  Dependence  should  not  be 
placed  upon  the  curette.  In  the  rapidly  growing  periosteal  t\pe  ampu- 
tation is  indicated,  and  while  permanent  cure  is  rare,  the  patient  secures 


710  TUMORS  OF  THE  LOWER  EXTREMITIES 

temporary    relief.      When    ulceration    has    taken    place    amputation    is 
doubly  indicated. 

Rare  Tumors  of  the  Leg.-.— Bone  cysts  producing  local  enlargements 
are  sometimes  seen.  These  may  be  imitated  by  chronic  osteomyelitis. 
Angiomas  are  usually  more  diffuse  than  cysts.  Each  of  these  may  be 
diagnosticated  by  the  :v-rays  or  by  opening  the  bone.  Periosteal  exostoses 
are  common  about  the  head  of  the  fibula  and  tibia,  and  are  often  seen 
on  the  subcutaneous  part  of  the  tibia.  In  this  situation  they  frequently 
result  from  chronic  periostitis  from  trauma.  Lipomas  may  occur  in 
the  deeper  parts  of  the  calf,  but  are  rare.  When  confined  beneath  the 
fascia  they  may  present  a  spindle-form  enlargement  the  consistency 
of  which  may  be  masked  by  the  fascia.  An  incision  into  the  tumor 
readily  clears  the  diagnosis. 


TUMORS    OF   THE   FOOT 

The  foot  is  in  general  subject  to  the  same  tumors  as  the  hand,  but 
there  are  exceptions  which  compel  a  brief  consideration  of  this  region. 

Sarcomas. — Melanotic  tumors  of  the  skin  of  the  foot  differ  from 
those  generally  found  on  the  extremities  in  that  they  tend  to  extend 
locally  and  do  not  so  readily  form  gland  metastases.  In  growth  and 
sometimes  in  structure  they  resemble  the  endotheliomas  more  than  the 
sarcomas.  Non-pigmented  lobulated  sarcomas  of  the  foot  are  rare. 
Giant-celled  sarcomas  of  the  tendon  sheath,  similar  to  those  of  the 
hand,  and  endosteal  and  periosteal  sarcomas  of  the  bones  of  the  foot, 
are  occasionally  encountered. 

At  this  point  may  be  described  a  peculiar  rather  frequent  lesion  of  the 
foot.  It  occurs  most  frequently  in  old  men,  particularly  in  those  affected 
with  extensive  arteriosclerosis.  It  forms  an  ulceration  on  the  sole  of 
the  foot  or  on  immediately  adjacent  parts,  presenting  crateriform 
openings  in  the  skin,  each  of  which  is  filled  by  a  fungating  mass  not 
unHke  exuberant  granulation  tissue  (Fig.  537).  The  ulcer  tends  gradually 
to  advance,  but  not  to  form  metastases.  When  removed,  it  tends  to 
recur  by  the  formation  of  nodules  in  the  vicinity  of  the  scar.  In  struc- 
ture it  may  in  general  resemble  sarcoma,  though  areas  endotheliomatous 
in  character  are  found  and  the  skin  bordering  the  lesion  shows  epithelial 
proliferation,  so  that  if  this  portion  alone  is  examined  carcinoma  is  likely 
to  be  diagnosticated.  Leukocytes,  fibrin,  and  other  evidence  of  granu- 
lation tissue  are  absent.     Wide  local  excision  results  in  a  cure. 

Diagnosis. — The  sarcomas  of  bone  are  apt  to  be  confused  with  inflam- 
matory affections,  notably  tuberculosis  and  syphilis.    The  inflammatory 


TUMORS  or  THE  TOOT 


711 


characttT  of  tin-  tornnr  is  siirticitiulv  ()l)vi()iis,  hut  in  tlie  latter  the 
difficult)  in  difKiciitiarion  rna\  W  very  fi;rcat.  The  A'-rays  show  a  diffuse 
involvcMuiit  in  syphilis  and  tin-  tlurapciitic  and  serological  tests  may 
be  applied  with  ailvanta<i;e. 

Treatment.      I  he  iliffuse  periosteal   tumors  alone  retjuire  amputation. 
Kach  of  the  otiurs  niay  he  treated  by  wide  local  excision. 

t'lt-  537 


Sarcoma  of  the  plantar  surface  of  the  foot. 


Carcinoma. — The  dorsum  of  the  foot  is  not  infrequenth'  the  seat  of 
carcmomas.  They  extend  slowly,  but  tend  ultimately  to  invade  the 
tendon  sheaths.  Their  diagnosis  and  treatment  does  not  differ  from 
similar  tumors  of  the  hand. 

Chondromas  and  Osteomas. — The  usual  cartilaginous  and  bony 
proliferations  may  appear  in  the  foot  and  resemble  in  all  respects  those 
on  the  hand.  Peculiar  bon\-  exostoses,  which  are  ver\-  characteristic, 
appear  between   the   terminal   phalanx   and   the   nail  of  the  great  toe 


712  TUMORS  OF  THE  LOWER  EXTREMITIES 

(Fig.  538).     Exostoses  of  the  os  calcis  has  been  described  and  attributed 
to  gonorrheal  infection. 

Fig.  538 


Subungual  exostosis. 

Rare  Tumors  of  the  Foot. — Lipomas  of  the  sole  of  the  foot  producing 
pad-like  thickening  of  the  sole,  are  sometimes  seen.  Cystic  enlarge- 
ment of  the  bursae  may  occur. 


INDEX 


Abdominal  \v;iI1,  carcinoma  of,  439 
desmoids  of,  439 
keloids  of,  439 
lipoma  of,  439 
sarcoma  of,  444 
Acidobacic  theory  of  etiology  of  tumors, 
Acquired  rumors,  4c 
Adenocarcinoma  of  stomach,  479 
Adenortbroma,  77 
of  breast,  398 
of  nasal  fossa,  310 
of  uterus,  561 
Adenoma,  145 

of  Bartholin's  glands,  626 
of  bile  ducts,  452 
of  bladder,  535 
diagnosis  of,  147 
of  face,  308 
intraglandular,  146 
of  liver,  452 
of  nasal  fossa,  3  10 
of  pancreas,  469 
parotid,  353 
polypoid,  145 
prognosis  of,  148 
of  prostate,  528 
treatment  of,  148 
of  vulva,  627 
Adenosarcoma  of  breast,  408 
Adrenal,  tumors  of.  522 
Age  as  a  factor  in  tumor  etiology,  54 
Alveolar  granuloma,  335 

sarcoma,  1 15 
Amputation  neuromas,  90 
Anaplasia,  43 
Aneur}"smal  varices,  132 
Aneurysms  of  bone,  697 
Angiomas,  127 
of  arm,  672 
of  breast,  414 
cavernous,  130 
diagnosis  of,  132 
of  face,  3C7 
of  hand,  679 
hemangiomas,  127 
lymphangiomas,  133 
parotid,  }S3 
of  scalp,  239 
of  shoulder,  666 


Angiomas  of  thyroid,  385 

treatment  of,  133 
,  Angiosarcoma,  1 12 
I  Appendix,  carcinoma  of,  505 

myomas  of,  504 

myxomas  of,  504 

polypi  of,  504 
44  sarcoma  of,  504 

tuberculosis  of,  507 
I  Arm,  angiomas  of,  672 

carcinomas  of,  671 

tibromas  of,  672 

lipomas  of,  671 

lymphomas  of,  681 

neuromas  of,  672 

papillomas  of,  672 
Atheromatous  cysts,  203.     See  Wens. 

of  scalp,  23  I 
Atrophy  in  carcinoma.  173 

in  niA'omas,  543 
Auscultation  in  diagnosis  of  tumors,  224 
Autonomy  of  cells  as  a  factor  in  etiolog}^  of 
tumors,  51 


B 


Back,  carcinoma  of,  449 

dermoids  of,  451 

fibromas  of,  448 

lipomas  of,  447 

papillomas  of,  447 

teratomas  of,  451 

tumors  of,  446 

developmental,  451 
Bacterial  theory  of  tumor  formation,  48 
Bile  ducts,  adenoma  of,  452 

carcinoma  of,  463 
Biological  character  of  tumors,  30 
Bladder,  adenomas  of,  535 

cysts  of,  535 

dermoids  of,  535 

hemangiomas  of,  535 

m3-omas  of,  ^^^ 

nodular  epithelial  tumors  of,  534 

sarcoma  of,  535 

syncytioma  of,  ^^^ 

tumors  of,  528 

villiform  tumors  of,  530 
diagnosis  of,  530 
treatment  of,  533 
Blastomyces  in  etiology  of  tumors,  50 


714 


INDEX 


Blood  changes  in  tumors,  34 
cysts  of  neck,  371 
vessels  of  tumors,  23 
Bone,  aneurysms  of,  697 

cysts  of,  697 
Borrmann's  theory  of  tumor  etiology,  39 
Botryomycosis,  217 
Brain,  carcinoma  of,  260 
cysts  of,  262 
endotheliomas  of,  259 
gliomas  of,  255 
granulomas  of,  261 
rare  tumors  of,  262 
sarcomas  of,  256 
tumors  of,  252 

cerebellar  ataxia  in,  253 
choked  disk  in,  253 
convulsions  in,  253 
facial  paralysis  in,  253 
headache  in,  252 
mental  aberration  in,  253 
motor  involvement  in,  253 
nystagmus  in,  253 
pathology  of,  255 
prognosis  of,  263 
symptoms  of,  252 
treatment  of,  264 
vertigo  in,  253 
vomiting  in,  253 
Branchiogenic  carcinoma,  367 
cysts,  372 
fistula,  372 
Breast,  adenofibromas  of,  398 
adenosarcomas  of,  408 
angiomas  of,  414 
atheromatous  cysts  of,  414 
carcinoma  of,  417 

acute  encephaloid,  422 
age  in,  417 
clinical  course  of,  427 
diagnosis  of,  429 

differential,  432 

from  granulomas,  433 
from  inflammation,  433 
from  interstitial  mastitis, 

432 
from  mixed  tumors,  433 
dissemination  of,  428 
glandular,  420 
Paget's  disease,  422 
prophylaxis  in,  433 
recurrence  after  operation  for,  436 
scirrhus,  418 
treatment  of,  435 

results  of,  437 
varieties  of,  418 
chondromas  of,  414 
chondrosarcomas  of,  408 
cystosarcomas  of,  408 
lipomas  of,  413 
male,  tumors  of,  418 
mixed  tumors  of,  408 


Breast,  mixed  tumors  of,  clinical  course  of, 
410 
diagnosis  of,  411 
treatment  of,  412 
myxoma  of,  414 
osteoma  of,  414 
Paget's  disease  of,  422 
papillomas  of,  413 
sarcoma  of,  415 

diagnosis  of,  416 
myxomatodes  of,  408 
phyllodes  of,  408 
treatment  of,  417 
scirrhus  of,  418 
syphilis  of,  433 
tuberculosis  of,  406 
symptoms  of,  407 
treatment  of,  408 


Calcareous    degeneration    of    carcinoma; 

173 

of  sarcomas,  117 
infiltration  in  myoma,  544 
Calf,  tumors  of,  708 
Carcinoma,  159 

of  appendix,  505 
basal-celled,  185 
of  bile  ducts,  463 
of  body  of  uterus,  581 
of  breast,  417 

of  buccal  mucous  membrane,  327 
causes  of  death  in,  176 
of  cecum,  499 

cells,  form  and  structure  of,  167 
of  cervix,  568.     See   also   Uterus,  car- 
cinoma of. 
of  chest,  391 

constitutional  effects  of,  176 
degeneration  in,  173 

atrophy,  173 

calcareous  infiltration,  173 

colloidal  degeneration,  175 

cornification,  176 

fatty  metamorphosis,  174 

hyalin,  176 

hydropic,  175 

necrosis,  174 

pearl  formation,  184 
diagnosis  of,  192 

clinical,  192 

microscopical,  194 
of  elbow,  671 
of  esophagus,  489 
of  face,  276 
of  Fallopian  tube,  624 
of  floor  of  mouth,  326 
of  foot,  711 
glandular,  187 
of  groin,  685 


INDEX 


715 


C\iriiiU)iii;i,    i^iowil!    ;in(l    clissrininaiiun    of 

ot  minis,  335 

of  hand,  675 

of  intestine,  491 

of  kidne}',  519 

KrompecluT's,  185 

of  lip,  283 

of  liver,  456 

of  lung,  3Q5 

of  nudiiistinum,  393 

metaniorpliosis  of,  174 

metastasis  of,  179 

mucous  membrane,  186 

of  nasal  fossa,  313 

of  neck,  364 

of  nose,  313 

of  orbit,  269 

of  ovary,  617,  620 

of  pancreas,  467 

of  papilla  of  Vater,  498 

of  parotid,  353 

of  penis,  636 

of  prostate,  524 

of  rectum,  501 

of  scalp,  241 

of  scrotum,  643 

secondar}'  changes  in,  173 

of  shoulder,  662 

of  sigmoid,  501 

squamous-celled,  182 

of  stomach,  470 

structure  of,  165 

macroscopic,  164 
microscopic,  165 

of  testicle,  655 

of  th\'roid  gland,  381 

of  tongue,  320 

treatment  of,  197 

t^-pes  of,  182 

of  uterus,  567 

of  vagina,  634 

of  vulva,  629 
Carotid  tumors,  387 

diagnosis  of;  390 
pathology  of,  387 
symptoms  of,  389 
treatment  of,  390 
Cavernous  angiomas,  130 

of  face,  304 
Cecum,  carcinoma  of,  499 
Cell  autonomy  in  etiology,  51 

type  in  tumors,  changes  in,  36 
Cephalhydrocele,  249 
Cerebral  ataxia  in  brain  tumors,  253 

cyst  of  orbit,  275 

hernia,  249 
Cervix,  carcinoma  of,  568.     See  also  Uterus, 
carcinoma  of. 

myoma  of,  536 
Chest,  carcmoma  of,  391 

keloids  of,  391 


Chest,  lipomas  of,  392 
sarcoma  of,  392 
syj)hilis  uf,  391 
tuberculosis  of,  391 
Cholesttatoma,  144 
Chondroma,  60-66 

I  developmental  malformations,  63 

displaced,  63 
false,  60 
of  fingers,  6H4 
of  foot,  71  I 
growth  of,  61 
of  hyoid  bone,  380 
of  jaw,  343 
of  parotid,  353 
prognosis  of,  63 
secondary-  changes  in,  62 
of  shoulder,  665 
structure  of,  61 
of  testicle,  655 
of  thigh,  697 
treatment  of,  63 
true,  60 
varieties  of,  62 
Chondrosarcomas,  107 
Chorioepitheliomas,  591 
Chromatophoromas,  154 
Classification  of  tumors,  19 
Cohnhemi's  theory  of  tumor  etiologv,  37 
Coley's  fluid  in  sarcoma,  123 
Colloid  carcinomas  of  breast,  426 

of  stomach,  477 
Condylomas,  156 
Congenital  tumors,  37 
Constitutional  effect  of  tumors,  33 
Cord,  cysts  of,  646 
tumors  of,  86 
Cornua  cutanea,  156 
Cranium,  osteomas  of,  247 
pneumatocele  of,  248 
sarcomas  of,  244 
tumors  of,  231 

metastatic,  247 
Cysts,  203 

of  bladder,  535 
of  bone,  697 
of  brain,  262 
branchiogenic,  372 
congenital,  205 
degenerative,  205 
diagnosis  of,  206 

macroscopic,  206 
microscopic,  206 
of  esophagus,  490 
of  hymen,  626 
of  jaw,  339 
of  neck,  370 
odontoid,  338 
of  orbit,  275 
of  ovary,  600 
follicle,  597 
luteal,  596 


716 


INDEX 


Cysts  of  ovary,  proliferative,  599 
pseudomucinous,  601 
serous,  605 

parovarian,  608 

proliferative,  204 

of  prostate,  528 

of  shoulder,  665 

simple  retention,  203 

of  spermatic  cord,  646 

thyroglossal,  318,  379 

thyroid,  318 

treatment  of,  206 

vaginal,  634 


D 


Dermoids,  205 
of  back,  451 
of  mediastinum,  393 
of  neck,  377 
of  orbit,  273 
of  scalp,  237 
Desmoids  of  abdominal  wall,  439 
Diagnosis  of  tumors,  general,  219 
age  as  factor  in,  220 
auscultation  in,  224 
clinical,  220 
color  as  factor  in,  223 
duration  in,  221 
family  history  in,  221 
form  in,  224 
history  in,  220 
inspection  in,  222 
laboratory  in,  225 
pain  in,  222 
palpation  in,  224 
physical  examination  in,  222 
preservation     of     tissue     re- 
moved for,  225 
relation  of  surrounding  tissue 

to,  223 
special   staining   methods   of, 
227 


surface  conformation  in,  223 


E 


ECCHONDROMAS,  6o 

Elbow,  carcinoma  of,  671 

lipomas  of,  671 

sarcomas  of,  667 
Elephantiasis,  79 

acquired,  80 

congenital,  79 

nervorum  of  scalp,  234 

of  scrotum,  643 

of  vulva,  626 
Embryoid,  207 

dermoids,  207 

mixed,  207 


Embryomas,  209 
of  liver,  455 
Enchondromas,  60 
Endemic  recurrence  of  tumors,  47 
Endotheliomas,  135 
of  brain,  259 
classification  of,  136 
diagnosis  of,  142 
of  face,  308 
hemangiomas,  139 
of  lungs,  396 
lymphangiomas,  137 
macroscopic  appearance  of,  137 
microscopic  appearance  of,  137 
of  orbit,  273 
of  ovary,  614 
peritheliomas,  140 
treatment  of,  143 
unusual  types  of,  141 
of  vagina,  635 
Epithelial  cysts  of  hand,  683 
Epulis,  333 

Esophagus,  carcinoma  of,  489 
cysts  of,  490 
fibromas  of,  490 
myomas  of,  490 
polyps  of,  490 
Esthiomene,  630 
course  of,  633 
diagnosis  of,  632 
etiology  of,  630 
pathology  of,  630 
prognosis  of,  633 
treatment  of,  634 
Etiology  of  tumors,  37 

acido-basic  theory  of,  44 
acquired,  40 
age  as  factor  in,  54 
anaplasia  in,  43 
bacteria  as  factor  in,  48 
blastomyces  in,  50 
Borrmann's  theory  of,  39 
change     of     tissue     balance     in, 

44 

Cohnheim's  theory  of,  37 

congenital,  37 

heredity  as  factor  in,  55 

influence  of  nutrition  on,  55 

metaplasia  in,  41 

parasites  in,  46 

protozoa  in,  49 

regression  in,  42 

Ribbert's  theory  of,  40 

sex  as  factor  in,  54 

syphilis  in,  56 

Thiersch's  theory  of,  44 

tissue  balance  as  factor  in,  44 

tuberculosis  in,  55 

Wilm's  theory  of,  40 
Exostoses,  59.     See  also  Osteomas,  false, 
of  great  toe,  712 
of  knee,  707 


/.\/>/;.\ 


71 


Extrailui.il  tumors,  266 
Extrusion  ot  niyomas,  541 
Eye,  glioma  of,  zbH 


F 


I'At  1:,  atknonias  of,  308 
oarcinonia  of,  276 

(Ucp,  2 83 

chafiiiosis  ot,  H)2 

im-tasrasis  in,  2H3 

supfrficial,  277 

trcatnitin  of,  294 

types  of,  276 
cavernous  anjiiomas  of,  304 
dermoids  of,  299 
tihromas  of,  299 
hemanfjiomas  of,  302 
li|iomas  ot,  3  I  5 
h  niiilian<i,iomas  of,  300 
moles  of,  297 
warts  of,  297 
Fallopian  tubes,  carcinoma  of,  624 

sarcoma  of,  624 

s\ncvtiomas  of,  624 
Fatty  degeneration  in  myomas,  545 
Femur,  aneur)'sms  of,  697 
bone  c^'sts  of,  697 
chondromas  of,  697 
lipomas,  699 
osteomas  of,  699 
Fibroadenoma,  77 
of  lip,  jj 
of  mamma,  398 
of  pharynx,  313 
Fibrolipoma,  77 
Fibromas,  73 
of  arm,  672 
of  back,  448 
classification  of,  73 
diagnosis  of,  81 
elephantiasis,  79 
of  esophagus,  490 
of  forearm,  672 
of  hand,  679 
hard,  73 
of  jaw,  337 
keloids,  78 
of  kidney,  520 
mixed,  77 
of  pharynx,  313 
prognosis  of,  82 
of  prostate,  528 
of  scrotum,  643 
secondar}'  changes  in,  75 
soft,  76 

of  stomach,  488 
of  thigh,  697 
of  tongue,  331 
treatment  of,  82 
of  vulva,  626 


f  ihioiiLis,  x.iniliDma,  Hi 
I'  ii)romyomas,  77 
Fibromyxomas,   77 
I*  ibrosarcomas,  77-104 
I'ingers,  botryomycosis  of,  682 

chondromas  of,  684 

icchoiulroses  of,  684 

epitlK-lial  cysts  of,  683 

ganglia  of,  683 

ostecjinas  of,  683 

sarcomas  of,  683 
Fistula,  branchial,  372 
Floor  of  mouth,  tumors  of,  315 
Follicle  cysts  of  ovary,  597 
Foot,  carcinoma  of,  711 

chondromas  of,  71  i 

osteomas  of,  71  i 

sarcomas  of,  710 


G 


Gall-blai)I)i;r,  rumors  of,  462 
Ganglia  of  hand,  683 
Giant-celled  sarcomas,  102 
Glanders,  217 
Gliomas,  83 

of  brain,  255 

of  cord,  86,  261 

of  eye,  268 

macroscopic  appearance  of,  83 

microscopic  appearance  of,  83 

mode  of  growth  of,  85 

of  retina,  86 

secondary  changes  in,  86 

treatment  of,  87 
Gliosarcomas,  1 12 
Granulomas,  210 

actinomycosis    216 

botryom3'cosis,  217 

glanders,  217 

of  gums,  335 

leprosy,  217 

m\'cosis  fungoides,  217 

rhinoscleroma,  217 

syphilis,  21 1 

macroscopic  appearance  of,  211 
microscopic  appearance  of,  212 

tuberculosis,  213 

macroscopic  appearance  of,  214 
microscopic  appearance  of,  214 
Grape  sarcomas  of  vagina,  635 
Groins,  carcinoma  of,  685 

lipomas  of,  688 

rare  tumors  of,  689 

sarcomas  of,  685 

diagnosis  of,  686 
treatment  of,  688 
Gummas  of  tongue,  331 
Gums,  carcinomas  of,  335 

epulides  of,  333 

fibromas  of,  337 


718 


INDEX 


Gums,  granulomas  of,  335 
lipomas  of,  337 
rare  tumors  of,  337 


H 

Hand,  angiomas  of,  673 
carcinoma  of,  675 
diagnosis  of,  678 
treatment  of,  678 
epithelial  cysts  of,  683 
fibromas  of,  679 
ganglia  of,  683 
granulomas  of,  682 
lipomas  of,  679 
papillomas  of,  680   - 
sarcomas  of,  673 

diagnosis  of,  674 
treatment  of,  674 
tenosynovitis  of,  683 
warts  of,  680 
Heart,  tumors  of,  394 
Hemangiomas,  127 
of  liver,  454 
of  tongue,  331 
of  vulva,  629 
Hematocele  of  scrotum,  645 
Hodgkin's  disease,  354 

clinical  course  of,  358 
etiology  of,  355 
pathology  of,  355 
Hydrocele  of  cord,  646 

of  round  ligament,  626 
of  scrotum,  644 
Hyoid,  tumors  of,  380 


Incarceration  of  myomas,  542 
Intestmes,  adenomas  of,  493 
carcinoma  of,  491 

course  of,  502 

diagnosis  of,  499 

prognosis  of,  503 
sarcoma  of,  493 
Intradural  cord  tumors,  266 
Intramedullary  tumors,  266 
Inversion  in  myomas  of  uterus,  542 


Jaws,  adamantomas  of,  33J 
chondromas  of,  339 
cysts  of,  338 
fibromas  of,  344 
osteomas  of,  344 
sarcomas  of,  339 

diagnosis  of,  341 
treatment  of,  342 


Keloids,  78 

of  chest,  391 
histology  of,  78 
Kidneys,  carcinoma  of,  519 
fibroma  of,  520 
hypernephroma  of,  512 
lipomas  of,  519 
mixed  tumors  of,  517 
sarcomas  of,  519 
tumors  of,  508 

diagnosis  of,  511 

hematuria  in,  509 
pain  in,  509 
tumor  in,  510 
etiology  of,  508 
Knee,  aneurysms  of,  707 
cysts  of,  707 
exostoses  of,  707 
lipomas  of,  706 
neurofibromas  of,  707 
osteomas  of,  707 
sarcomas  of,  701 
Krompecher  epitheliomas,  185 
Kruckenburg's  tumor  of  ovary,  620 


Laboratory  diagnosis  of  tumors,  225 
Lacrymal  glands,  tumors  of,  275 
Legs,  tumors  of,  686 
Leiomyomas,  69 

of  face,  308 

of  uterus,   436.      See    also    Myoma    of 
uterus. 
Lepros}^  217 

Leukemic  nodules  in  liver,  455 
Lip,  angioma  of,  302 

carcinoma  of,  283 
causes  of,  284 
frequency  of,  284 
prognosis  of,  294 

chancre  of,  293 
Lipofibromas,  77 
Lipomas,  67 

of  abdominal  wall,  439 

of  arm,  671 

of  back,  447 

of  chest,  392 

course  of,  67 

diagnosis  of,  69 

of  elbow,  671 

of  face,  315 

of  femur,  699 

of  foot,  712 

of  forearm,  671 

of  groin,  688 

of  hand,  679 

of  kidney,  519 

of  knee,  706 


INDEX 


719 


Lipomas  of  li\  it,  455 
of  ntck,  37« 
of  orbit,  275 
of  scalp,  286 
of  scrotum,  643 
of  slioulck-r,  662 
of  stomach,  4SS 
of  thifih.  688 
of  t(»nnuc,  331 
of  vulva,  626 
Liposarcomas,  1 12 
Liver,  atlenomas  of,  4152 
carcinomas  of,  456 
t-mbryomas  of,  455 
hemangiomas  of,  454 
leukemia  of,  455 
lipomas  cf,  455 
l\niphansiomas  of,  455 
myomas  of,  455 
sarcomas  of,  458 
syphilis  of,  455 
tumors  of,  452 
primary,  452 
secondary,  459 

clinical  symptoms  of,  459 
diagnosis  of,  460 
Lower  extremities,  tumors  of,  685 
Lungs,  carcinoma  of,  395 
endotheliomas  of,  396 
sarcomas  of,  396 
tumors  of,  395 
benign,  395 
secondary,  396 
Luteal  cysts  of  ovary,  596 
Lymphangioendotheliomas,  137 
Lymphangiomas,  133 
of  arm,  681 
diagnosis  of,  134 
of  face,  300 
of  liver,  455 

of  mouth  and  tongue,  328 
of  vulva,  629 
Lymphatics  of  tumors,  23 
L\-mph  cysts  of  mouth,  320 

of  neck,  370 
Lymphomas  of  mediastinum,  393 
L\mphosarcomas,  100 
of  neck,  360 
of  orbit,  267 


M 


Malignant  lymphomas,  354 

myomas,  549 
Mastitis,  chronic  interstitial,  401 
Mamma,  adenoHbroma  of,  397 
carcinoma  of,  417 

complications  after  operation,  436 
course  of,  427 

degeneration  in,  calcareous,  427 
colloid,  426 


Mamma,  carcinoma  of,  diagnosis  of,  difPer- 
ential,  432 
from  granulomas,  433 
from  inflammation,  433 
from  mixed  tumors,  433 
from  senile  mastitis,  432 
history  in,  430 
inspection  in,  43  I 
dissemination  of,  428 
encephaloid,  422 
glandular,  420 
Paget's,  422 
prognosis  in,  437 
prophylaxis  of,  433 
recurrence  after,  436 
!  results  of  operation  ff)r,  437 

treatment  of,  435 
types  of,  422 
cysts  of,  402.  411,  414,  415,  416 
fibroadenomas  of,  398 
mastitis,  chronic  interstitial,  401 

senile,     parenchymatous     hyper- 
trophic, 401 
Mediastinum,  carcinoma  of,  393 
dermoids  of,  393 
lymphoma  of,  393 
sarcoma  of,  393 
Medullary  carcinoma  of  stomach,  475 
Melanomas,  154 
Melanctic  papillomas,  152 
Melanosarcomas,  99 
Meningocele  spuria,  249 
Metaplasia  in  tumors,  41 
Metastasis  of  tumors,  27 
benign,  31 
in  carcinoma,  179 
by  contact,  30 
in  gastric  carcinoma,  475 
m  Hodgkm's  disease,  360 
laws  controlling,  30 
local,  28 
regional,  28 
remote,  29 
retrograde,  29 
in  sarcoma,  118 
in  skull,  247 
in  thyroid,  385 
Mixed-celled  sarcomas,  99 
tumors,  207 

of  breast,  408 

clinical  course  of,  410 
treatment  of,  412 
of  kidne}',  517 
of  parotid,  345 

clinical  course  of,  349 
diagnosis  of,  350 
treatment  of,  350 
of  testicle,  646 

clinical  course  of,  652 
pathology  of,  647 
treatment  of,  653 
of  uterus,  549 


720 


INDEX 


Moles,  152.     See  Papillomas. 

of  face,  297 
Mouth,  tumors  of,  315-320 
Mucous  papillomas,  155 
Multiple  adenoma  of  liver,  453 

myelomas,  125 
Mycosis  fungoides,  217 
Myeloma,  125 

Bence- Jones  albumin  in,  126 
diagnosis  of,  126 
multiple,  125 
structure  of,  125 
Myomas  (leiomyomas),  69 
of  bladder,  535 
of  cervix,  539 
degeneration  of,  70 
differentiation  of,  70 
of  esophagus,  490 
growth  of,  70 
of  liver,  455 

macroscopic  appearance  of,  69 
malignant  (myosarcoma),  72,  113 
microscopic  appearance  of,  69 
mixed,  71 
of  parotid,  353 
of  round  ligament,  563 
of  stomach,  488 
of  testicle,  655 
treatment  of,  72 
of  uterus,  536 

accidents  in  development,  540 
biological  changes  in,  550 
changes  in  other  organs,  551 
diagnosis  of,  554 

differential,  554 

from  ovarian  cysts,  554 
from  pregnancy,  555 
from  pus  tubes,  554 
from  rare  tumors,  556 
heart  in,  551 
hemorrhage  in,  551 
pain  in,  553 
-pressure  in,  553 
reflex  disturbance  in,  554 
extrusion  of,  541 
forms  of,  536 
incarceration  of,  542 
influence  of,  on  form  of  uterus,  540 
intraligamentous,  539 
inversion  of,  542 
ovaries  and  tubes  in,  551 
pregnancy  in,  563 

accidents  of  development  in, 

566 
causes  of  abortion  in,  564 
degeneration  of  tumor  in,  564 
obstruction  to  delivery,  564 
treatment  of,  564 

removal  of  fetus  in,  565 
of  tumor  in,  564 

and    uterus    in, 
565 


Myomas  of  uterus,  prognosis  of,  557 
secondary  changes  in,  543 
atrophy,  543 
degeneration,  calcareous, 

544 
fatty,  545  _ 
hemorrhagic,  546 
myxomatous,  543 
sarcomatous,  547 
necrosis,  545 
sequestration  of,  541 
submucous,  538 
subserous,  538 
torsion  of  pedicle,  540 
treatment  of,  558 

hysterectomy   in,   abdominal, 
560 
vagmal,  559 
palliative,  558 
of  vagina,  63^ 
Myosarcoma,  113 
of  orbit,  269 
Myxofibromas,  jj 
Myxomas,  64 

course  of  development  of,  67 
degeneration  in,  66 
diagnosis  of,  66 
macroscopic  appearance  of,  64 
of  mamma,  414 
microscopic  appearance  of,  64 
mixed  forms  of,  64 
of  testicle,  647 
of  thigh,  692 
treatment  of,  66 
Myxomatous  degeneration  of  myomas,  543 

of  sarcomas,  116 
Myxosarcomas,  no 


N 


Nasal  fossa,  adenofibromas  of,  310 

adenomas  of,  310 

carcinomas  of,  313 

cysts  of,  310 

enchondromas  of,  310 

osteomas  of,  310 

papillomas  of,  hard,  310 

rare  tumors  of,  310 

sarcomas  of,  312 
polyps,  309 
Navel,  tumors  of,  445 
Neck,  carcinoma  of,  364 

primary,  364 

secondary,  367 
cysts  of,  370 

blood,  371 
dermoids  of,  377 
fibromas  of,  379 
hydroceles  of,  370 
lipomas  of,  378 
lymph  glands  of,  sarcoma  of,  362 


i\i)i:.\ 


721 


Niilc,  lynipliomas  of,  inalifin;ii)t,  354 

lymphosarcomas  of,  360 

sarcoma  of,  scconilary,  370 

wens  of,  377 
Ni-r\es  of  tumors,  23 
Ntimtfihromas  of  sciatic  lurvc,  6(>5 
Nciirof-liomas,  S7 
Neuromas,  8S 

amputation,  90 

macroscopic  appearance  of,  90 

microscopic  appearance  of,  <>l 

|ile.\iform,  <>o 

jiseudoneuromas,  89 

traumatic,  90 

true,  88 

types  of,  89 
Nevi,  152 

Nutrition  as  a  factor  in  tumor  etiology,  55 
Nystagmus  in  brain  tumors,  253 


Odontoid  cysts,  338 
Odontomas,  337 
Orbit,  carcinoma  of,  269 
cysts  of,  cerebral,  275 

serous,  275 
dermoids  of,  273 
endothelioma  of,  273 
hemangioma  of,  275 
lipoma  of,  275 
lymphosarcoma  of,  276 
myosarcoma  of,  269 
osteoma  of,  271 
sarcoma  of,  267 
teratoma  of,  275 
Osteoma,  57 

of  breast,  414 

of  cranium,  247 

false,  59 

of  fingers,  683 

of  foot,  711 

of  jaw,  344 

of  knee,  707 

of  nasal  fossa,  310 

of  orbit,  271 

of  shoulder,  663 

of  thigh,  699 

true,  57 

diagnosis  of,  57 

growth  of,  58 

macroscopic  appearance  of,  57 

microscopic  appearance  of,  58 

treatment  of,  59 

varieties  of,  58 
Osteosarcoma,  109 
Ovaries,  adenocystomas  of,  600 
carcinomas  of,  617 

clinical  course  of,  621 

diagnosis  of,  622 

metastasis  in,  619,  622 
46 


Ovaries,  carcinomas  of,  pathology  of,  618 
secondary,  618 
treatment  (jf,  622 
cysts  of,  596 

diagnosis  of,  609 

ditterential,  610 

from  ascites,  612 
from  carcinoma,  611 
from  myomas,  61 1 
from  pregnancy,  610 
from     tuboiivarian     ab- 
scess, 610 
follicle,  597 
luteal,  596 
proliferative,  599 
pseudomucinous,  601 

clinical  course  of,  604 
malignant  changes  in,  605 
pathology  of,  601 
serous,  605 

clinical  course  of,  608 
pathology  of,  605 
treatment  of,  612 
dermoids  of,  623 
endotheliomas  of,  614 

clinical  course  of,  624 
pathology  of,  623 
treatment  of,  624 
fibromas  of,  615 
sarcomas  of,  613 

diagnosis  of,  616 
treatment  of,  616 
teratomas  of,  624 


Facet's  disease  of  nipple,  422 
Palliative  treatment  of  tumors,  229 
Palpation  in  tumor  diagnosis,  224 
Pancreas,  adenomas  of,  469 

carcinomas  of,  467 

cysts  of,  465 

sarcomas  of,  469 
Papilla  of  Vater,  carcinoma  of,  463,  498 
Papillomas,  150 

of  arm,  672 

of  back,  417 

of  breast,  413 

condyloma,  156 

cornu  cutanea,  156 

epithelial,  150 

fibrous,  150 

of  hands,  68c 

melanotic,  152 

mucous,  155 

of  nasal  fossa,  310 

of  penis,  64c 

of  scalp,  233 
Parasitic  theory  of  tumor  etiology,  46 
Parathyroid,  tumors  of,  387 
Parenchyma  of  tumors,  21 


722 


INDEX 


Parotid,  adenomas  of,  353 
angiomas  of,  353 
carcinomas  of,  353 
chondromas  of,  353 
mixed  tumors  of,  345 

clinical  course  of,  349 

diagnosis  of,  350 

macroscopic    appearance    of, 

345 
microscopic     appearance     of, 

347 
treatment  of,  350 
myomas  of,  353 
rare  tumors  of,  353 
sarcomas  of,  353 
Parovarian  cysts,  608 
Penis,  carcmoma  of,  636 
diagnosis  of,  639 
etiology  of,  636 
pathology  of,  636 
symptoms  of,  638 
treatment  of,  642 
induration  of,  640 

clinical  course  of,  641 
diagnosis  of,  642 
etiology  of,  641 
pathology  of,  641 
treatment  of,  642 
papillomas  of,  640 
sarcomas  of,  640 
wens  of,  640 
Periductal  myxomas,  408 
Perigastritis       in       stomach       carcinoma, 

483 
Periosteal  cysts,  339 
Peritheliomas,  140 
Pharynx,  tumors  of,  309-313 
Plexlform  neuromas,  90 
Pneumatocele,  248 
Polyps  of  esophagus,  492 
of  intestine,  493 
nasal,  309 
of  stomach,  488 
Popliteal  space,  aneurysms  of,  707 
cystic  tumors  of,  707 
exostoses  of,  707 
osteomas  of,  707 
Proliferative  cysts  of  the  ovaries,  599 
Prostate,  adenomas  of,  528 
carcinomas  of.  524 
diagnosis  of,  527 
symptoms  of,  526 
treatment  of,  528 
cysts  of,  528 
myomas  of,  528 
rare  tumors  of,  528 
sarcoma  of,  528 
Protozoa  as  a  factor  in  etiology  of  tumors, 

49 
Pseudoleukemia,  354 
Pseudomucinous  cysts  of  ovary,  601 
Pseudoneuromas,  89 


R 


Ranulas,  sublingual,  315 

diagnosis  of,  317 

treatment  of,  317 
Rectum,  qarcinoma  of,  501 

papillomas  of,  501 
Regression  in  tumors,  42 
Retrogressive  changes  in  tumors,  36 
Retroperitoneal  tumors,  469 
Rhabdomyomas,  72 
Rhinophymas,  217,  308 
Ribbert's  theory  of  origin  of  tumors,  40 
Rodent  ulcer  of  vulva,  630 
Round  ligament,  hydrocele  of,  626 

myomas  of,  563 
Round-celled  sarcomas,  97 
Riickschlag  in  tumors,  42 


Sarcocarcinoma,  116 
Sarcomas,  92 

of  abdominal  wall.  444 

alveolar,  115 

angiosarcoma,  112 

of  appendix,  504 

of  bladder,  535 

of  brain,  256 

of  breast,  415 

of  calf,  709 

cause  of  death  in,  119 

of  chest,  392 

chondrosarcoma,  107 

classification  of,  96 

constitutional  disturbance  in,  119 

of  cranium,  244 

degeneration  of,  116 

calcareous,  117 

lipomatous,  116 

myxomatous,  116 
diagnosis  of,  119 

clinical,  119 

microscopic,  120 
edema  of,  117 
of  elbow,  667 
of  Fallopian  tube,  624 
of  femur,  689 
of  fingers,  673 
of  foot,  710 
giant-celled,  102 
gllosarcoma,  112 
of  groin,  685 
of  hand,  673 
higher  types  of,  104 
of  intestine,  493 
of  jaw,  339 
of  kidney,  519 
of  knee,  701 
of  liver,  458 
of  lymph  glands,  362 


IXDEX 


72:j 


Sarcomas,  l^'mphosarcoina.  loo 

niain>si()|iic  appearana-  of,  i  i6 

of  mccliastiniini,  393 

imlanoric,  »;(; 

im-tastasis  in,  I  iH 

microscopic  appearance  of,  120 

mixed-celled,  </> 

myosarcoma,  1 13 

myxosarcoma,  1 10 

of  nasal  fossa,  3 1 2 

of  neck,  362,  370 

necrosis  of,  i  iH 

of  orbit,  267 

osteosarcoma,  109 

of  ovary,  613 

of  pancreas,  469 

of  parotid,  353 

of  penis,  640 

prognosis  of,  122 

of  prostate,  528 

round-celled,  97 

of  scalp,  244 

of  scrotum,  643 

of  slicnilder,  656 

spindle-celled,  97 

of  stomach,  487 

structure  of,  93 

of  tendon  sheaths,  673 

of  testicle,  655 

of  thigh,  689 

of  thyroid,  386 

of  tongue,  327 

topographical  relations  of,  95 

treatment  of,  122 

operations  in,  123 
sera  in,  122 
.r-ra3's  in,  123 
of  umbilicus,  445 
of  uterus,  547 
of  vagina,  635 
varieties  of,  96 
of  vulva,  627 
Scalp,  angiomas  of,  239 
atheroma  of,  231 
carcinoma  of,  241 
dermoids  of,  237 
elephantiasis  nervorum  of,  243 
endotheliomas  of,  242 
lipomas  of,  236 
papillomas  of,  233 
sarcomas  of,  244 
syphilis  of,  245 
tuberculosis  of,  242 
wens  of,  231 
Sciatic  nerve,  tumors  of,  695 
Scirrhus  of  mamma,  418 
Scrotum,  carcinoma  of,  643 
dermoids  of,  642 
elephantiasis  of,  643 
fibromas  of,  643 
hematoceles  of,  644 
hydroceles  of,  644 


Scrotum,  lipomas  of,  643 
sarcomas  of,  643 
wens  of,  642 
Sebaceous  cysts,  203      See  also  Wens. 
Senile     parenchymatous     hypertrophy     of 

mamma,  401 
Secpjestrarion  in  myomas,  541 
Shoidder,  angiomas  of,  666 
carcinoma  of,  662 
chondromas  of,  66:; 
cysts  of,  665 
lipomas  of,  662 
metastasis  of,  662 
osteomas  of,  663 
sarcomas  of,  656 
Sigmoid,  tumors  of,  501 
Sinus  pericranii,  248 
Skull,  metastasis  in,  247 
Small  intestines,  tumors  of,  497 
Soft  Hbromas,  76 
Solid  tumors  of  ovaries,  613 
Spermatic  cysts,  646 
Spina  bifida,  451 
Spinal  cord,  tumors  of,  264 

diagnosis  of,  266 
extradural,  266 
intradural,  266 
intramedullary,  266 
symptoms  of,  265 
treatment  of,  266 
Stomach,  adenocarcinomas  of,  479 

adenomas  of,  488.     See  also  Polyps, 
carcinoma  of,  470 
blood  in,  481 
colloid,  477 
diagnosis  of,  481 

differential,  482 

exploratory    incision    in. 

484 
from   pernicious   anemia, 

483 
etiology  of,  470 
medullary,  475 
metastasis  in,  475 
mode  of  extension  of,  474 
pathology  of,  472 
scirrhus,  477 
site  of,  473 
s3'mptoms  of,  479 

gastric  contents,  480 
hemorrhage,  480 
pain,  480 
treatment  of,  486 
operative,  487 
palliative,  487 
fibromas  of,  488 
lipomas  of,  488 
m\omas  of,  488 
polyps  of,  488 
sarcomas  of,  488 
Stroma  of  tumors,  22 
Structure  of  tumors,  21 


724 


INDEX 


Structure  of  tumors,  bloodvessels  in,  23 

lymphatics  in,  23 

nerves  in,  23,  25 

parenchyma  of,  21 

stroma  of,  22 
Subungual  exostosis,  712 
Supraorbital  osteomas,  272 
Syncytioma  malignum,  591 

diagnosis  of,  594 

etiology  of,  591 

of  Fallopian  tubes,  624 

macroscopic    appearance    of,    592 

594 
metastasis  in,  593 
microscopic    appearance    in,    591, 

594 

prognosis  of,  595 

secondary  changes  in,  593 

of  testicle,  655 

treatment  of,  595 

of  uterus,  691 
Syphilis  of  chest,  391 

as  factor  in  etiology  of  tumors,  56 

of  liver,  455 

of  scalp.  245 

of  spinal  cord,  265 


Teeth,  tumors  of,  337 
Tendon  sheaths,  tumors  of,  673 
Teratomas  (embryomas),  209 
of  back,  451 
of  orbit,  275 
of  ovary,  624 
of  vagina,  635 
Testicle,  carcinoma  of,  655 
chondromas  of,  655 
mixed  tumois  of,  646 

clinical  course  of,  652 
diagnosis  of,  652 
macroscopic  structure  of,  647 
microscopic  structure  of,  649 
pathology  of,  647 
treatment  of,  653 
myomas  of,  655 
myxomas  of,  655 
sarcomas  of,  655 
syncytiomas  of,  655 
Thigh,  chondroma  of,  697 
fibroma  of,  697 
lipoma  of,  688,  699 
myxoma  of,  692 
osteomas  of,  699 
sarcomas  of,  689 
Thyroglossal  cysts,  318,  377 
Thyroid  cysts,  380 

gland,  adenomas  of,  381 
carcinomas  of,  381 
cysts  of,  380 
rare  tumors  of,  386 


Thyroid  gland,  sarcomas  of,  386 
Tissue  balance  in  etiology  of  tumors,  44 
Tongue,  carcinoma  of,  320 
diagnosis  of,  325 
metastasis  in,  324 
treatment  of,  326 

fibromas  of,  331 

gummas  of,  331 

hemangiomas  of,  331 

lipomas  of,  331 

lymphangiomas  of,  329 

sarcomas  of,  327 
Torsion  of  pedicle  in  myomas  of  uterus,  540 

in  ovarian  cysts,  604 
Toxins  of  tumors,  34 
Traumatic  neuromas,  90 
True  neuromas,  88 
Tuberculosis  of  appendix,  507 

of  breast,  486 

of  cecum,  500 

of  chest,  391 

as  factor  in  etiology  of  tumors,  55 

of  hand,  683 

of  vulva,  629 
Tunica  vaginalis,  tumors  of,  644 
Turbinates,  polypoid  hypertrophy  of,  310 


u 


Umbilicus,  carcinoma  of,  445 
congenital,  445 
sarcoma  cf,  445 
Upper  extremity,  tumors  of,  656 
Urethra,  tumors  of,  642 
Uterus,  adenomyomas  of,  561 
clinical  course  of,  562 
treatment  of,  562 
body  of,  carcinoma  of,  581 
age  in,  581 
diagnosis  of,  586 

differential,  586 

from    adenofibroma, 

586 
from  polypoid  endo- 
metritis, 586 
from     postoperative 
endometritis,  587 
from     submucous 
fibroids,  588 
pathology  of,  581 
prognosis  of,  588 
symptoms  of,  585 
cervix  of,  carcinoma  of,  567 
diagnosis  of,  575 

differential,  577 

from  cicatricial,  579 
from    cystic    degen- 
eration of  cervix, 

578 
from  everted  cervical 
mucosa,  577 


INDEX 


725 


I  tiriis,    iLi  \  i.\  of,   i;inini»m;i  of,    diiignosis 
of,        ilifFtTcntiiil, 
from  pol\'|)K,  577 
from  sypliilis,  579 
from     tuberculosis, 

from     ulceration     of 
cervix,  579 
macroscopic,  575 
microscopic,  58c 
etiology  of,  567 
fetor  in,  57^ 
lu-morriiage  in,  573 
metastasis  in,  572 
pain  in,  574 
symptoms  of,  573 
mixed  tumors  of,  549 
myomas  of,  536.     Hre  also   Myoma  of 

uterus, 
sarcomas  of,  547 


Vagina,  cysts  of,  634 

endotheliomas  of,  635 

myomas  of,  634 

sarcomas  of,  635 
\'ertigo  in  brain  tumors,  253 
Villous  tumors  of  bladder,  530 
Vulva,  adenomas  of,  626 

carcinomas  of,  629-634 


\'ulva,  elephantiasis  of,  626 
esthiomene  of,  630 
Hbromas  of,  626 
hemangiomas  of,  629 
lipomas  of,  626 
Ivniphangiomas  of,  629 
rodent  ulcer  of,  630 
sarcoma  of,  627 
tuberculosis  of,  629 


w 

Warts,  150.     See  also  Papillomas. 

of  face,  297 

of  hands,  6H1 
\\  ens,  203 

of  face,  2H9 

of  mamma,  414 

of  neck,  377 

of  penis,  640 

of  scalp,  231 

of  scrotum,  642 


Xanthomas,  81 
X-rays  in  sarcomas,  123 

in  treatment   of  epitheliomas  of  face, 
294 


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